^AtUvmtt  SItbrarg 


\ 


SYPHILIS 


SYPHILIS 


A  Treatise  for  Practitioners 


BY 


EDWARD   L.  KEYES,  Jr.,  A.B,  M.D.,  Ph.D. 

CLINICAL   PROFESSOR   OF   GENITO-URINARY   SURGERY,    NEW   YORK    POLYCLINIC 

MEDICAL    SCHOOL    AND    HOSPITAL;     LECTURER    ON    SURGERY, 

CORNELL  UNIVERSITY  MEDICAL  school;    SURGEON 

TO  ST.  Vincent's  hospital 


WITH  SIXTY-NINE  IILUSTRATIONS  IN   THE    TEXT  AND 
NINE  PLATES,    SEVEN  OE   WHICH  ARE    COLORED 


new  york  and   london 
d.  appleton   and   company 

1908 


l^-(f^l  5 


Copyright,  1908,  by 
D.   APPLETON   AND   COMPANY 


PRINTED   AT  THE   APPLETON   PRESS 

NEW  YORK,    U.    S.    A.  '^^ 


FOREWORD 


A  WEARIED  medical  public,  already  surfeited  with  text-books, 
monographs,  and  essays  upon  syphilis  and  kindred  matters,  may 
well  ask  in  resentful  indignation :  Why  this  new  work  upon 
syphilis  ? 

Being  the  father  of  the  writer  and  the  godfather  of  many  of 
the  generalizations  advanced,  I  think  I  may  answer. 

The  facts  upon  which  the  volume  rests  are  the  classified  cases 
from  the  private  office  books  covering  forty  years  of  continuous 
work  by  myself  along  syphilological  lines,  ten  years  of  work  in 
the  same  field  by  my  son,  and  some  gleanings  from  the  twenty 
extra  years  included  in  Dr.  Van  Buren's  case  books,  which  the 
office  has  inherited — making  a  retrospect  of  sixty  years. 

In  this  considerable  mass  of  experience  there  is  much  matter 
of  value  that  would  have  remained  buried  but  for  the  resurrec- 
tion afforded  it  by  this  volume. 

The  generalizations,  based  upon  the  statistics  above  referred 
to,  corroborate  quite  uniformly  similar  generalizations  of  other 
authors  often  based  upon  statistics  numerically  superior ;  these 
latter  statistics  being  sometimes  largely  from  the  hospital  and 
dispensary  point  of  view. 

In  certain  of  the  views  advanced,  where  this  treatise  differs 
from  the  majority  of  text-books,  I  am  willing  to  share  the  respon- 
sibility with  my  son. 

E.  L.  Keyes. 

109  East  Thirty-fourth  Street. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/syphilistreatiseOOkeye 


PREFACE 


In  order  to  make  this  work  essentially  a  practical  one,  it 
has  been  founded  upon  the  2,500  cases  of  syphilis  observed  and 
adequately  recorded  in  our  office  case  books  during  the  past 
forty  years.  The  number  of  these  cases  might  have  been  many 
times  multiplied  by  the  compilation  of  dispensary  records ;  but 
this  would  only  have  confused  the  picture.  For  the  records 
taken  of  charity  cases  are  so  hasty  and  inaccurate,  their  histories 
so  vague  and  incomplete,  their  disease  so  complicated  by  alco- 
holism and  privation,  their  adhesion  to  any  one  clinic  and  course 
of  treatment  so  brief  and  intermittent,  that  it  is  not  fair  to  com- 
pare them  with  cases  that  have  been,  in  the  main,  intelligently 
treated  and  watched  for  a  number  of  years. 

Yet  it  is  perhaps  too  much  to  say  that  even  these  cases  have 
been  intelligently  treated.  All  have  received  treatment  at  our 
hands,  but  a  large  minority  have  received  most  of  their  treat- 
ment, and  especially  of  their  important  early  treatment,  at  the 
hands  of  others.  That  the  result  leaves  something  to  be  desired 
may  be  inferred  from  the  forty  per  cent  incidence  of  tertiaries 
we  have  to  record.  Yet  this  result,  which  makes  our  cases  more 
interesting,  if  less  creditable,  represents  fairly  well  the  status  of 
syphilis  in  the  middle  and  upper  classes  in  New  York,  and  in 
some  measure  throughout  the  United  States,  during  this  term 
of  years. 

During  the  last  decade  an  increased  appreciation  of  the  hor- 
rors of  syphihs,  and  a  new  method — the  intramuscular  injection 
of  mercury — for  its  control,  have  certainly  lessened  the  severity 
of  the  disease,  and  we  may  feel  assured  that,  even  without  the 


viii     .  PREFACE 

serum  diag-nosis,  immunization,  and  therapy,  which  the  future 
seems  to  promise,  syphilis  during  the  next  forty  years  will  be 
far  less  destructive,  because  far  more  intelligently  treated,  than 
ever  before. 

Be  that  as  it  may — and  it  is  very  difficult  even  to-day  to 
define  accurately  in  what  good  treatment  consists  and  to  distin- 
guish which  case  has  received  it — the  contemplation  and  tabula- 
tion of  these  cases  has  proved  most  valuable,  not  so  much  for 
the  statistics  derived  from  them  as  for  the  point  of  view  they 
have  enforced  and  elucidated. 

This  point  of  view,  in  large  measure  inherited  from  and  con- 
stantly inculcated  by  my  beloved  father,  is  his  contribution  to 
this  work;  and  if  the  development  of  syphilology  has  spread 
these  chapters  over  many  more  pages  than  those  of  his  earlier 
work  upon  the  same  topic,  the  spirit  of  the  two  is  the  same.  I 
can  but  regret  that  the  advance  of  science  permits  me  to  incor- 
porate so  little  of  the  letter  of  that  work,  and  hope  that  thereby 
the  text  has  not  lost  all  its  interest. 

Whether  the  new  theories  that  have  poured  in  upon  us  since 
the  discovery  by  Schaudinn  of  the  Spirocheta  pallida  will  destroy 
this  point  of  view ;  whether  it  will  prove,  for  instance,  that,  after 
all,  there  are  "  periods  "  in  syphilis,  or  that  "  paternal  heredity  " 
is  possible,  matters  not  at  all.  With  this  discovery  we  see  the 
dawn  of  a  new  era  of  syphilology ;  we  hope  for  complete  mas- 
tery of  the  disease;  we  pray  that  we  may  live  to  see  the  day 
when  syphilis  shall  be  reduced,  from  a  volume  to  a  chapter,  from 
a  scourge  to  a  mere  annoyance.  Yet  we  fear  that  many  a  year 
shall  pass  ere  some  such  volume  as  this  one  shall  cease  to  be  of 
practical  interest  to  the  student  and  the  practitioner. 

Such  is  the  excuse  for  the  publication  of  this  book — to 
express  practically  a  view  of  syphilis  that  has  been  two  genera- 
tions in  the  making,  and  to  elucidate  this  by  American  statistics. 
Concerning  the  matter  herein  set  down,  it  is  impossible  to  be 
egotistical.     The  world's  great  authorities,  Fournier,  Neumann, 


PREFACE 


IX 


Lang,  Hutchinson,  Finger,  and  Taylor — to  mention  only  a  few 
to  whom  a  special  debt  is  due — have  been  drawn  upon  freely 
for  information,  and  reference  upon  disputed  points  has  been 
made  for  the  convenience  of  the  student  to  the  latest,  the  most 
comprehensive,  or  the  most  accessible  monographs.  Thus  we 
hope  to  spare  the  reader  aimless  divagations  among  the  litera- 
ture, and  ourselves  the  laborious  sciolism  of  copious  bibliography. 

The  many  chapters  on  special  subjects  have  been  a  source  of 
grave  concern,  lest  the  writing  of  all  of  them  by  the  same  hand 
should  sacrifice  accuracy  of  matter  to  uniformity  of  manner. 
But  my  friends  have  kindly  come  to  my  aid.  With  a  courtesy 
for  which  I  cannot  be  too  grateful,  Dr.  L.  M.  Hurd  has  reviewed 
the  chapters  upon  Syphilis  of  the  Nose,  the  Throat,  and  the 
Upper  Air  Passages ;  Dr.  E.  G.  Zabriskie,  those  upon  Syphilis 
of  the  Nervous  System ;  Dr.  J.  I.  Middleton,  that  upon  Syph- 
ilis of  the  Eye ;  and  Dr.  John  Howland  those  upon  Hereditary 
Syphilis. 

Finally,  while  including  in  my  general  debt  of  gratitude  all 
those  whose  writings  or  whose  illustrations  upon  syphilis  I  have 
been  able  to  lay  my  hands  on,  I  must  acknowledge  a  more  pre- 
cise indebtedness  to  the  many  others  who  have  lent  kindly  per- 
sonal aid  to  the  matter  in  this  volume :  to  my  father,  facili 
principi ;  to  my  associate.  Dr.  Chetwood,  for  privilege  to  tabulate 
cases  observed  by  him,  as  well  as  for  the  keen  interest  with 
which  he  has  shared  the  labor  of  testing  various  methods  of 
treatment;  to  Drs.  G.  H.  Fox  and  J.  A.  Fordyce,  for  many 
original  photographs ;  to  Drs.  H.  G.  Piffard,  J.  Lincoln  Davis, 
Prince  A.  Morrow,  E.  L.  Shurley,  and  W.  A.  Pusey  for  illus- 
trations ;  to  Dr.  W.  R.  Bross  for  his  contribution  on  Syphilis 
and  Insurance ;  to  Dr.  E.  W.  Caldwell  and  Dr.  L.  G.  Cole  for 
skiagraphs ;  and  to  Dr.  C.  H.  Jaeger  and  Dr.  L.  E.  La  Fetra 
for  the  loan  of  cases  from  whom  these  skiagraphs  were  taken. 

109  East  Thirty-fourth  Street, 
New  York  City. 


TABLE   OF   CONTENTS 


CHAPTER    I 

SYPHILIS   IN    RELATION    TO    PUBLIC   HEALTH 

The  prevalence  of  syphilis — Syphilis  in  marriage — The  prophylaxis  of 
syphilis 

CHAPTER    II 

THE   GENERAL   CHARACTERISTICS   OF   SYPHILIS 

History  of  syphilis — Acquired  syphilis:  The  primary  lesion ;  The  secon- 
dary lesions ;  The  tertiary  lesions ;  The  parasyphilids ;  Are  there 
periods  of  syphilis? — Hereditary  syphilis — Clinical  types  of  the 
disease:  Mild  early  syphilis ;  Malignant  early  syphilis ;  Mild  but 
persistent  syphilis ;  Relapsing  syphilis ;  Malignant  late  syphiUs ; 


Mild  late  syphilis 


CHAPTER    III 

ETIOLOGY   OF    SYPHILIS 

The  Spirocheta  pallida:  Methods  of  staining;  Diagnosis;  Where  may 
5.  pallida  be  found ;  Distribution  and  fate — Experimental  syph- 
ilis: Inoculation;  Prophylaxis;  Inoculation  immunity;  Serum 
diagnosis  and  treatment 22-34 

CHAPTER    IV 

THE   NATURE   OF   SYPHILIS 

The  contagiousness  of  gumma:  Persistence  of  spirocheta — Cause  of 
relapses:  Trauma  and  syphilis;  The  cause  of  parasyphilids^ 
Immunity:  Racial  immunity;  Is  our  race  immunized? — The 
second  attack  of  syphilis — Syphilis  in  woman — Pathology:  Lesions 
of  the  capillaries ;  Disposition  of  the  spirochetae ;  Lesions  of  the 
larger  vessels 35-54 


XU  TABLE   OF   CONTENTS 

CHAPTER   V 
TRANSMISSION    OF   SYPHILIS 

PAGES 

Extragenital  and  non-sexual  infection:  Extragenital  chancre — Age  of 
ificidence — The  probability  and  possibility  of  infection:  Does  ex- 
posure necessarily  imply  infection?  What  is  the  probability  of 
infection  from  contact  by  kissing  or  sexual  intercourse  with  a 
person  known  to  be  syphilitic  ?  When  does  syphilis  cease  to  be 
infectious? — Syphilis  and  marriage      .......      55-64 

CHAPTER   VI 

SYPHILITIC   INHERITANCE 

Syphilis  and  maternity — The  theory  of  syphilitic  heredity:  Paternal- 
heredity;  Maternal  conceptional  heredity;  Maternal  post-con- 
ceptional  heredity;  Acquired  syphilis  in  infancy — Hereditary 
syphilis  of  the  third  generation 65-77 

CHAPTER   VII 

THE    COURSE    OF    SYPHILIS 

The  onset:  In  man;  In  woman;  Duration  of  primary  and  secondary 
incubation — The  secondary  symptoms:  Definition ;  Differentiation 
between  secondary  and  tertiary  lesions ;  Secondary  toxemia ;  Local 
sj'mptoms ;  Duration  of  the  secondary  symptoms ;  Nature  of  late 
secondaries;  Infectiousness  of  late  secondaries;  Prevention  of 
late  secondaries — The  tertiary  symptoms:  Definition ;  Occurrence ; 
Relapses ;  The  effect  of  treatment ;  The  effect  of  alcohol ;  Regions 
involved;  Incidence  of  all  late  lesions — The  parasyphilids  or 
syphilitic  dystrophics:  Definition;  Varieties;  Tabes  dorsaUs  and 
paresis ;  Syphilitic  spinal  paralysis 78-112 

CHAPTER   VIII 

DIAGNOSIS 

Syphilo phobia — Means  of  diagnosis:  Laboratory  diagnosis;  Clinical 
diagnosis — Diagnosis  at  different  periods  of  the  disease:  The 
initial  stage ;  The  secondary  outbreak ;  In  a  period  of  calm ;  Later 
relapses — Differential  diagnosis 1 13-123 

CHAPTER    IX 

PROGNOSIS 

The  patient's  constitution:  Interaction  with  other  diseases  and 
diatheses — The  patient's  environmeni:  Climate;  Age;  Debility 
and  trauma — The  patient's  habits:  Alcohol;  Tobacco — The 
effect  of  treatment — TJie  lapse  of  time — Life-insurance  estimates  1 24-137 


TABLE   OF   CONTENTS  .  xiii 

CHAPTER    X 
PRINCIPLES   OF   THE    TREATMENT    OF    SYPHILIS 

PAGES 

Prevention — General  principles  of  treatment — The  routine  treatment: 
Hygiene ;  lodids  do  not  prevent  relapse ;  Mercury  does  prevent 
relapse;  Mercury  is  a  tonic;  In  the  routine  treatment  tonic 
doses  of  mercury  are  more  effective  than  poisonous  doses;  So 
long  as  a  sufficient  amount  of  mercury  is  exhibited  it  matters 
not  whether  it  is  given  by  the  mouth,  by  the  skin,  or  by  injection; 
The  symptomatic  treatment:  For  early  secondary  lesions  mercury; 
for  early  painful  symptoms  iodid ;  Gummatous  lesions  may  be 
cured  by  iodid  but  better  by  mixed  treatment ;  Sclerotic  lesions 
and  lesions  difficult  to  classify  require  mixed  treatment;  Lesions 
of  the  nervous  system  require  treatment  for  short'  periods  with 
intermissions  of  hygienic  treatment;  Symptomatic  treatment 
should  always  be  vigorous  and  continued  after  the  lesion  has 
apparently  healed;  Vigorous  treatment  is  that  which  effects 
prompt  improvement;  Local  treatment  avails  little    .         .      13S-150 

CHAPTER    XI 

THE  ROUTINE  AND  SYMPTOMATIC  TREATMENT 

The  routine  tonic  treatment:  How  to  administer  treatment;  The 
Vigorous  interrupted  method ;  The  modern  interrupted  method ; 
The  continuous  tonic  treatment ;  Method  of  administering  mer- 
cury; Tonic  treatment;  Tonic  treatment  after  late  relapses; 
When  to  begin  routine  treatment — Treatment  of  the  lesions  of 
syphilis 1 51-160 

CHAPTER    XII 

PHYSIOLOGICAL   EFFECTS   AND    TOXICOLOGY   OF   MERCURY 

Beneficial  effects  of  mercury — Toxicology:  Salivation;  Treatment  of 
salivation;  Entero-colitis ;  Nephritis;  Dermatitis;  111  effects  of 
prolonged  mercurialization ;  Contraindications      .        .        .      1 61-168 

CHAPTER    XIII 

ADMINISTRATION    OF    MERCURY 

Internal  administration:  Protiodid ;  Gray  powder ;  Bichlorid ;  Blue  pill ; 
Calomel ;  Tannate ;  Other  preparations ;  Rules  for  treatment ;  Do 
not  give  opium ;  Do  not  begin  with  full  dose ;  An  occasional  inter- 
inission ;  Merits  of  internal  treatment— Intramusciclar  injection: 


xiv  TABLE   OF   CONTENTS 

PAGES 

Bichlorid;  Benzoate;  Biniodid;  Salicylate;  Gray  oil;  Calomel; 
Method;  Frequency;  Merits  of  various  injections;  Disadvan- 
tages; Advantages — Inunction:  Preparations  employed;  Tech- 
nic;  Duration;  Merits — Fumigation:  Salts  employed;  Technic; 
Merits — Intravenous  injection:  Solutions  employed;  Technic; 
Complications — Intratracheal  injection — Rectal  administration — 
Comparison  of  various  methods:  For  efficiency ;  For  comfort  .      1 69-1 9 1 


CHAPTER   XIV 

THE    lODIDS:    MIXED    TREATMENT 

Therapeutic  indications — lodism:  Coryza;  Indigestion;  Acne  and 
other  skin  lesions;  Toxemia;  Salivation;  Neuralgia;  Edema; 
Other  lesions— Method  of  administration  and  dosage:  The  one 
hundred  per  cent  solution;  The  minim  drop;  The  time  of  ad- 
ministration ;  Dilution ;  The  diluent ;  Prevention  of  iodism ;  Sub- 
stitutes for  potassium  iodid ;  Dose ;  Duration  of  treatment ;  How 
to  increase  the  dose — Mixed  treatment — The  test  course     .      192-205 


CHAPTER   XV 

CHANCROID 

Definition — The  streptohacilhis — Frequency — Methods  of  contagion — 
Situation  and  number — Symptoms  and  course:  Incubation ;  Onset ; 
The  ulcer — Complications:  The  mixed  sore;  Inflammation;  De- 
struction of  freedom ;  Gangrene  and  phagedena ;  Lymphangitis ; 
Inguinal  adenitis — Diagnosis — Treatment:  Abortive ;  Palliative ; 
Prevention  of  bubo;  Treatment  of  complications        .        .      206-221 


CHAPTER    XVI 

THE    INITIAL   LESION 

The  chancre:  Synonyms;  Description;  Pathology;  Multiple  chancre; 
Types ;  The  eroded  chancre ;  The  Hunterian  chancre ;  The  Indur- 
ated papule ;  Exceptional  varieties ;  Complications ;  Lymphan- 
gitis; The  mixed  sore;  Inflammation;  Gangrene  and  Phagedena; 
Transformation  into  a  mucous  papule;  Vegetations;  Duration; 
Reinduration ;  Diagnosis ;  Prognosis ;  Treatment — Characteristics 
of  chancre  in  various  locations:  Of  the  male  genitals;  Urethral; 
Of  the  female  genitals;  Cervical;  Extragenital  chancre;  Buccal; 
Tegumentary^T/z^  adenitis  of  chancre:  Symptoms;  Unusual 
varieties;  Diagnosis;  Treatment 222-241 


TABLE  OF  CONTENTS  xv 

CHAPTER  XVII 

DIAGNOSIS   OF   THE    INITIAL   LESION 

PAGES 

Requirements  for  diagnosis:  The  test  of  time — Differential  diagnosis: 
Of  genital  chancre;  Herpes;  Scabies;  Chancroid;  Gumma; 
Table  of  differential  diagnosis — Differential  diagnosis  of  chancre 
of  the  mouth:  Of  the  lip;  Within  the  mouth;  Vincent's  angina; 
Chancre  of  the  tongue 242-252 


CHAPTER   XVIII 

SYPHILITIC    TOXEMIA 

Acute  syphilitic  toxemia:  Hematology;  Pathological  anatomy; 
Fever  of  early  syphilis;  General  debility;  Prodromes;  Nervous 
symptoms;  Symptoms  of  local  congestion;  Of  the  skin  and 
mucous  membrane ;  Of  the  lymph  nodes ;  Of  the  bones ;  Of  the 
joints  and  muscles ;  Of  the  brain  and  meninges ;  Of  the  abdominal 
viscera;  Alopecia — Chronic  syphilitic  toxemia:  The  fever  of  late 
syphilis ;  Arterial  and  visceral  sclerosis ;  Amyloid  degeneration  of  , 
the  viscera 253-270 


CHAPTER    XIX 

SYPHILIS   OF   THE    SKIN:    GENERAL   CHARACTERISTICS 

General  clinical  characteristics:  Slow  and  progressive  development; 
Polymorphism;  Absence  of  inflammation;  Absence  of  pain  and 
itching;  Peculiar  color;  Rounded  form;  The  scale;  The  crust; 
The  ulceration;  The  scar;  General  clinical  characteristic  of 
secondary  and  tertiary  syphilids— 6^^n^ra/  pathological  char- 
acteristics: The  papule ;  The  macule ;  The  tubercle ;  The  gumma 

271-279 

CHAPTER   XX 

SECONDARY   SKIN    SYPHILIDS 

The  macular  syphilid:  Varieties;  Duration;  Diagnosis;  Differential 
diagnosis — The  papular  syphilid:  Varieties ;  Diagnosis ;  Differen- 
tial diagnosis — The  vesicular  syphilid — The  bullous  syphilid — The 
pjustular  and  crusted  syphilids:  Herpetiform ;  Varicelloid ;  Acnei- 
form;  Impetiginous;  Ecthymatous — The  squamous  syphilid: 
Diagnosis — The  pigmentary  syphilid 280-301 


xvi  TABLE  OF  CONTENTS 


CHAPTER  XXI 

SECONDARY   SYPHILIDS   OF   SPECIAL   REGIONS   INCLUDING 
ONYCHIA 

PAGES 

Moist  papules:  Erosions  and  condylomata — Squamous  eruptions  of 
the  palms  and  soles— Onychia:  Atrophic;  Detachment  of  the  nail; 
Hypertrophic ;  Other  varieties — Paronychia:  Squamous ;  Ulcera- 
ting; Treatment — Eruptions  in  the  scalp:  Pustular  or  crusted 
syphilids ;  Vegetating  syphilid — Eruptions  about  the  face:  Corona 
veneris;    Diffuse    infiltration;   Vegetation      ....      302-312 

CHAPTER   XXII 

TERTIARY   SYPHILIDS   OF   THE    SKIN 

The  tubercular  syphilid:  The  tubercle;  Disseminated  eruptions; 
Grouped  eruptions;  Diagnosis;  Treatment — The  ulcerative  tuber- 
cular syphilid:  Phagedena ;  Characteristics  of  the  lesion ;  Ecth}^- 
ma;  Rupia;  Treatment;  Other  crusted  lesions;  The  tertiary 
ulcer:  Prognosis,  Diagnosis,  Differential  diagnosis,  Treatment 
—Subctitaneous  gumma:  Single;  Confluent;  Prognosis;  Diag- 
nosis; Differential  diagnosis;  Treatment        ....      313-335 

CHAPTER    XXIII 

SECONDARY   SYPHILIS   OF   THE    MUCOUS   MEMBRANES 

Distribution — Etiology — Classification — The  macular  syphilid— The 
erosive  or  papular  syphilid:  The  erosion ;  The  eroded  papule ;  The 
vegetating  papule  or  condyloma — The  ulcerative  syphilid:  The 
simple  ulcer;  The  ulcerated  papule  or  condyloma — The  squamous 
syphilid — Diagnosis: 'Erosion  and  nlcevation  inside  the  mouth; 
In  the  female  genitals ;  On  the  skin  of  the  genitals  and  elsewhere ; 
Condylomata — Treatment:  Local  treatment — Secondary  syphi- 
lids of  the  ear       336-34S 

CHAPTER   XXIV 

TERTIARY    SYPHILIDS    OF   THE    MOUTH,    PHARYNX.    NOSE. 

AND    EAR 

Occurrence — Influence  of  tobacco — Relapses:  Concurrence  of  lesions— 
Lesions  of  the  lips — Lesions  of  the  tongue:  Leukoplakia ;  Etiology; 
Characteristics;  Diagnosis;  Prognosis;  Treatment;  Diffuse  scle- 
rotic glossitis ;  Gumma  of  the  tongue ;  Differential  diagnosis — 
Lesions  of  the  tonsil:  Infiltration;  Gumma — Lesions  of  the 
pharynx — Lesions  of  the  velum:  Prognosis;  Treatment — Lesions 
.  of  the  palate:  Treatment — Lesions  of  the  nose:  Symptoms; 
Diagnosis;  Treatment;  Other  rare  and  obscure  conditions; 
Syphiloma ;  Fibroid  degeneration ;  Atrophic  rhinitis — Lesions  of 
the  ear:  Of  the  internal  ear 349-367 


TABLE    OF   CONTENTS  Xvii 

CHAPTER    XXV 

SYPHILIS   OF   THE   NERVOUS   SYSTEM 

PAGES 

Etiology:  Race;  Sex;  Age;  Treatment;  Alcohol;  Date  of  onset — 
Pathology  of  brain  lesions:  Arterial  lesions;  Meningeal  lesions; 
Secondary  changes — Pathology  of  lesions  of  the  spinal  cord: 
Lymphocytosis  of  the  cerebro-spinal  fluid;  Early  secondary 
meningitis;  Prognosis;  Treatment  —  Symptoms:  Prodromes; 
Onset;  Course — Prognosis — Treatment 368-385 

CHAPTER   XXVI 

SYPHILIS   OF   THE   NERVOUS   SYSTEM 

Clinical  types — Ocular  paralyses:  Motor  oculi;  Abducens;  Fourth 
nerve ;  Optic  neuritis ;  Site  of  lesion ;  Prognosis — Hem-iplegia  and 
apoplexy:  Onset ;  Clinical  type ;  Prognosis — Aphasia — Deafness: 
Symptoms :  Prognosis ;  Treatment  — •  Facial  paralysis  —  Other 
form-s  of  paralysis — Epilepsy:  Jacksonian  epilepsy — Insanity: 
Mania;  Delusional  insanity;  Progressive  dementia  with  paral- 
ysis ;  Dementia  without  paralysis — Syphilis  of  the  spinal  cord: 
Symptoms ;  Meningitis  and  meningo-myelitis ;  Paraplegia ;  Syphi- 
litic ataxia  with  exaggerated  reflexes — Parasyphilids — Syphilis 
of  the  nerves — Diagnosis:  Nerves;  Brain  and  cord        .         .      386-410 

CHAPTER    XXVII 

SYPHILIS   OF   THE    EYE 

Iritis:  Pathology;  Symptoms;  Complications;  Diagnosis;  Prognosis; 
Treatment — Chorio-retinitis  and  retinitis:  Pathology;  Symptoms; 
Varieties;  Prognosis;  Treatment — Optic  neuritis:  Pathology; 
Symptoms;  Diagnosis;  Treatment — Gumma  of  the  iris;  Of  the 
ciliary  body;  Of  the  choroid — Conjunctival  syphilis — Keratitis 
and  scleritis — Tarsitis — -Dacroadenitis — Orbital  lesions         .      411-423 

CHAPTER    XXVIII 

SYPHILIS    OF    THE    BONES 

Varieties:  Occurrence ;  Bilateral  lesions-,  Multiple  lesions — Etiol- 
ogy— Pathology:  Osteoperiostitis:  Gummatous  osteoperiostitis; 
Osteomyelitis — Symptoms  of  medullary  lesions;  Of  periosteal 
lesions — Diagnosis:  Differential  diagnosis — Treatment — Prog- 
nosis— Lesions  of  special  bones:  Cranial  bones;  Fingers;  Lower 
jaw;  Sternum;  Vertebral  column  .  .  .  •  1  •  •  4^4-443 
2 


xviii  TABLE    OF   CONTENTS 


CHAPTER   XXIX 

SYPHILIS    OF    JOINTS,    MUSCLES,    TENDONS    AND    APONEUROSES, 
BURS^    AND    TENDON    SHEATHS 

PAGES 

Syphilis  of  the  joints:  Arthralgia ;  Hydrarthrosis ;  Pseudo-rheumatism ; 
Tertiary  arthritis ;  Deforming  arthritis ;  Syphilis  of  the  muscles: 
Contracture ;  Interstitial  myositis ;  Gumma ;  Myositis  ossificans ; 
— Syphilis  of  the  tendons  and  aponeuroses — Syphilis  of  the  bursce 
— Syphilis  of  the  tendon  sheaths 444-451 

CHAPTER   XXX 

SYPHILIS   OF   THE   AIR   PASSAGES 

Syphilis  of  the  larynx:  Secondary  lesions;  Erythema;  Erosion;  Pap- 
ules; Condylomata;  Infiltration;  Symptoms;  Diagnosis;  Treat- 
ment ;  Tertiary  lesions ;  Ulcerations ;  Gumma ;  Fibroid  degenera- 
tion ;  Perichondritis ;  Paralysis ;  Symptoms ;  Diagnosis ;  Prognosis ; 
Treatment — Syphilis  of  the  trachea,  bronchi  and  lungs:  Tracheal 
ulceration ;  Lesions  of  hereditary  pulmonary  syphilis ;  Lesions  of 
acquired  pulmonary  syphilis;  Bronchiectasis;  Complications, 
mixed  infection  with  tuberculosis;  Symptoms  of  tracheal  and 
bronchial  syphilis ;  Symptoms  of  hereditary  pulmonary  syphilis ; 
Symptoms  of  acquired  pulmonary  syphilis ;  Diagnosis ;  Differen- 
tial diagnosis;  Treatment 452-468 

CHAPTER   XXXI 

SYPHILIS    OF    THE    LIVER 

Occurrence — Pathology:  Hereditary  lesions;  Secondary  lesions; 
Tertiary  lesions;  Associated  lesions — Symptoms:  Neoplastic 
type ;  Cirrhotic  type ;  Cachectic  type ;  Febrile  type ;  Silent  type 
— Diagnosis — Prognosis — Treatment 469-477 

CHAPTER   XXXII 

SYPHILIS    OF   THE    GENITAL   ORGANS 

Syphilis  of  the  testicle:  Occurrence;  Pathology;  Symptoms;  Prog- 
nosis ;  Diagnosis ;  Treatment — Chancre  redux:  Occurrence ;  Diag- 
nosis; Treatment 478-483 

CHAPTER    XXXIII 

SYPHILIS    OF   THE   CIRCULATORY   AND    LYMPHATIC    SYSTEMS 

Syphilis  of  the  heart:  Functional  derangement;  Sclerogummatous 
myocarditis;   Pericarditis   and   endocarditis;   Bradycardia   and 


TABLE    OF   CONTENTS  xix 

PAGES 

Stokes-Adams  syndrome — Lesions  of  the  coronary  arteries: 
Angina  pectoris — Syphilis  of  the  aorta:  Aneurysm;  Frequency 
and  date  of  incidence ;  Diagnosis ;  Treatment — Syphilis  of  the  * 

arteries  of  the  extremities:  Aneurysm;  Arterial  obstruction ;  In- 
termittent claudication;  Reynaud's  disease;  Gangrene — Syph- 
ilis of  the  veins:  Acute  phlebitis ;  Sclerogummatous  phlebitis — 
Syphilis  of  the  lyniphatics:  Qvivarad^  oi\h&\yra.-^\).xiO(ie.?,        .      484-491 


CHAPTER   XXXIV 

SYPHILIS   OF   VARIOUS   VISCERA 

Syphilis  of  the  digestive  organs:  Salivary  glands ;  Pancreas ;  Esophagus ; 
Syphilis  of  the  stomach ;  Intestinal  syphilis ;  Syphilis  of  the 
rectum;  Gumma;  Ulcer;  Ano-rectal  syphiloma;  Stricture — 
Syphilis  of  the  urinary  organs:  Syphilis  of  the  kidney ;  Nephritis ; 
Diagnosis ;  Treatment ;  Sclerogummatous  nephritis ;  Symptoms ; 
Diagnosis — Syphilis  of  the  pelvic  organs:  Of  the  bladder;  Of  the 
prostate  and  seminal  vesicles ;  Pelvic  cellulitis — Syphilis  of  the 
ovaries  and  uterus 492-503 

CHAPTER    XXXV 

HEREDITARY    SYPHILIS    IN    UTERO    AND    IN    INFANCY 

Occurrence  and  mortality — Fetal  syphilis:  Pathology;  Symptoms — 
Infantile  syphilis:  Inflammation  of  the  nose ;  Inflammation  of  the 
skin;  The  lesion;  Polymorphism;  Regional  distribution;  Con- 
fluence; Pemphigus;  Circumscribed  maculo-papular  syphilid; 
Diffuse  maculo-papular  syphilid — Lesions  of  special  regions: 
Erosions  of  the  lips;  Ano-genital  lesions;  Onychia  and  paro- 
nychia; Lesions  of  the  scalp;  Tubercular  and  gummatous 
syphilid ;  Lesions  of  mucous  membrane ;  Aphonia ;  Osteochon- 
dritis; Periostitis;  Dactylitis;  Arthritis;  Myositis;  Lympha- 
denitis; Orchitis;  Inflammation  of  the  liver  and  spleen; 
Pneumonia;  Lesions  of  the  nervous  system;  Lesions  of  the 
eyes;  Lesions  of  the  ear;  Mixed  infection  of  the  skin;  Of  the 
respiratory  tract;  Sepsis;  Tuberculosis;  Rachitis — Syphilitic 
dystrophies .         .         .         .         .      504—526 

CHAPTER   XXXVI 

HEREDITARY  SYPHILIS:  RELAPSES:  LATE  LESIONS:  DIAGNOSIS: 
PROGNOSIS:  TREATMENT 

Relapses  in  early  childhood — Late  hereditary  syphilis:  Diffuse  peri- 
ostitis ;     Parenchymatous    keratitis ;    Treatment — Stigmata    of 


XX  TABLE   OP  CONTENTS 

PAGES 

hereditary  syphilis:  Hutchinson's  triad;  Dental  stigmata; 
Hutchinson's  teeth;  Foumier's  teeth;  Ocular  stigmata;  Auditory- 
stigmata — Diagnosis  of  hereditary  syphilis:  In  infancy ;  Examina- 
tion of  the  family  record ;  Diagnosis  in  later  years — Prognosis — 
Treatment  in  infancy;  Local  treatment;  Treatment  of  relapses 
after  the  second  year 527-542 


Index 


543 


LIST   OF   PLATES 


PLATE 

I.- 

Fig. 

I. 

Fig. 

2. 

Fig. 

3- 

Fig. 

4- 

Fig. 

5- 

Fig. 

6. 

Fig. 

7- 

PLATE 

II.- 

Fig. 

I. 

,  FACING 

PAGE 

I.— SPIROCHETE 24 

— Spirocheta  pallida. 

— Spirocheta  pallida  and  Spirocheta  refringens. 

— Spirocheta  buccalis. 

— Spirocheta  buccalis. 

— Spirocheta  pallida. 

■Spirocheta  halanitidis. 

■Spirocheta  halanitidis. 

—SPIROCHETE    IN   TISSUES 28 

Macular  syphilid.     Section  of  venous  capillary,  showing 
distribution  of  spirochetae  and  phagocytosis  by  fibroblasts 
and  leukocytes. 
Fig.   2. — Spirochetae  in  bone  marrow  in  hereditary  syphilitic  os- 
teochondritis. 

PLATE    III.— SPIROCHETE    IN   TISSUES      .....     30 
Fig.   I. — Hereditary  syphilis  of  liver. 
Fig.   2. — Skin  affected  by  hereditary  syphilitic  pemphigus. 

PLATE    IV.— EXTRAGENITAL   CHANCRE     .....   234 
Fig.   I. — Chancre  of  breast. 
Fig.   2. — Chancre  of  tonsil. 

PLATE   v.— EXTRAGENITAL   CHANCRE 238 

Fig.   I. — Chancre  of  the  lip. 
Fig.   2. — Chancres  of  the  tongue. 
Fig.  3. — Chancre  of  the  lip. 

PLATE    VI.— THE    ONSET    OF    SYPHILIS 276 

PLATE    VII.— PIGMENTARY   SYPHILID    OF   NECK         .        .   300 

PLATE   VIII.— TUBERCULAR   SYPHILID      .        .        .        .        .312 

PLATE    IX.— TERTIARY   LESIONS   OF   THE   TONGUE  .        .352 

Fig.  I. — Sclerotic  glossitis. 

Fig.  2. — Superficial  sclerotic  glossitis. 

Fig.  3. — Gumma. 

Fig.  4. — Tertiary  ulcer. 


LIST   OF    ILLUSTRATIONS   IN   TEXT 


FIG.  PAGE 

I. — Microphotograph  of  chancre 48 

2. — Microphotograph  of  symmetrical  atrophy  of  skin  with   syphihs     49 

3. — Microphotograph  of  tubercular  sj^phiUd 50 

4. — Strepto-bacillus  of  Ducrey 206 

5. — Strepto-bacillus  of  Ducrey 207 

6. — Chancroids  of  penis .         .         .         .210 

7. — Chancroids  of  penis 211 

8. — Chancroids  of  vulva .212 

9. — Pathology  of  eroded  chancre 223 

10. — Pathology  of  ulcerated  chancre         .         .         .         .         .         .         .224 

II. — Hunterian  chancre      . 226 

12. — Scabies  of  penis  resembling  chancre 227 

13. — The  "mixed  sore"       .         .         . 229 

14. — Chancre  of  vulva:  papulo-macular  syphilid    .         .         .         .         -236 

15. — Herpes  progenitalis 244 

16. — Syphilitic  alopecia       . 266 

17. — Pathology  of  syphilitic  tubercle 279 

18. — Macular  syphilid .         .         .         .281 

19. — Labial  chancre:  macular  syphiUd 282 

20. — I\Iaculo-papular  syphilid 283 

21. — Back  view  of  same 285 

22. — Confluent  papular  syphilid         .         .         ,         .         .         .         .         .287 

23. — Papular  syphiUd,  marked  on  neck 288 

24. — Papular  syphilid  on  a  negro      .         .         .         .         .         .         .         .289 

25. — Acneiform  syphilid 294 

26. — General  papulo-squamous  syphilid 297 

27. — Confluent  papulo-squamous  sj^philid 298 

28. — Circinate  papulo-squamous  syphiUd 299 

29. — Macular  syphilid  of  palm 304 

30. — Squamous  syphilid  of  palm 305 

31. — Eczema  of  palm,  resembling  syphihs -305 

32. — Annular  syphilid  of  soles 306 

33. — Sj^philid  of  sole  with  thickening  of  epidermis         .         .         .         -307 
34. — Confluent  tubercular  syphilid  of  nose      .         .         .         .         .         -315 

35. — Serpiginous  tubercular  syphilid 316 

36. — Pathology  of  serpiginous  tuberculo-ulcerative  syphilid         .         -317 
37. — ^Serpiginous  tuberculo-ulcerative  syphilid        .         .         .         .         -318 
xxii 


LIST   OF    ILLUSTRATIONS    IN   TEXT  xxiii 

FIG.  PAGE 

38. — Serpiginous  tuberculo-ulcerative  syphilid        ,        ,         .        .        .319 
39. — Serpiginous  tuberculo-ulcerative  syphilid        ..       ,         .        .        .320 

40. — Phagedenic  ulcers 321 

41. — Rupia 323 

42. — Crusted  tertiary  ulceration 325 

43. — ^Tertiary  ulcer 326 

44. — Gummatous  ulcer:  tibial  node 329 

45. — Ancient  gummatous  leg  ulcers 333 

46. — Pathology  of  condyloma 339 

47. — Macular  syphilid  and  condylomata 340 

48. — Condylomata 341 

49. — Ulcers  of  soft  palate   .         .         .         . 360 

50. — The  same,  healed 360 

51. — Loss  of  septum  in  acquired  syphilis 365 

52. — Skiagraph  of  syphilitic  osteo-periostitis 427 

53. — Skiagraph  of  syphilitic  osteo-periostitis 428 

54. — Skiagraph  of  saber  tibia 429 

55. — Tibial  node 430 

56. — Skiagraph  of  gummata  of  femur  and  tibia 432 

57.^ — Extensive  gummatous  destruction  of  skull 440 

58. — Syphilitic  dactylitis 441 

59. — Syphilitic  bursitis 450 

60. — Syphilitic  pneumonia 463 

61. — Gumma  of  liver  . 472 

62. — Congenital  syphilis      . '     .        .        .  508 

63. — Sunken  nose  (en  lorgnette) 511 

64. — Sunken  nose 511 

65. — Maculo-papular  (hereditary)  syphilid 515 

66. — Syphilitic  osteo-chondritis  (skiagraph) 519 

67. — Saber  tibia 530 

68. — Hutchinson's  teeth 535 

69. — Irregular  and  decayed  teeth,  due  to  but  not  characteristic  of 

syphiHs •        •        •  535 


CASES   CITED 


Extragenital  infection:  syphilis  insontium  (I)     .         .           ...  4 
Extragenital  infection :  syphilis  insontium :  hereditary  syphilis :  pro- 
longed syphilis  (II) 4 

Severe  toxemia  in  female :  tuberculosis  (III)  .       .         .         .         .         .        ig 

Alcoholism:  malignant  early  syphilis  (IV) 19 

Malignant  early  syphilis :  carcinoma  (V) 19 

Malignant  early  syphilis  in  a  healthy  woman :  destruction  of  velum, 

gumma  of  tongue,  necrosis  of  mandible  (VI)  ....  20 
Malignant  early  syphilis:  hemiplegia,  death  (VII)  ....  20 
Illustrating  the  general  nature  of  syphilitic  relapses:  twelve  years 

of  health;  then  neuralgia,  gummatous  periostitis  (VIII)     .         .        39 
Companion  case:  four  years'  interval;  then  gumma  of  nasal  septum, 
gumma  of  parietal  bone,   laryngeal  syphilis,   chancre   redux, 
cerebral  syphilis  (IX) 40 


Alleged  second  attack  of  syphilis  (Lang)  (X) 

Alleged  second  attack  of  syphilis  (Koebner)  (XI) 

Cases  of  extragenital  infection  (Foumier) 

Cases  of  exposure  to  syphilis  without  infection     . 

The  fate  of  eleven  men  exposed  to  syphilis,  gonorrhea,  and  chancroid 

(Connors) 60 

Squamous  syphilid  during  the  sixth  and  the  twenty-fifth  year  (XII)        88 

Secondary  syphilid  of  tongue  in  the  twenty-third  year  (XIII)  .        .        89 

Pustular  syphilid  in  the  thirtieth  year  (XIV) 89 

Relapsing  erosive  lesions  of  tongue  for  twenty  years  (XV)         .         .        90 

Squamous  syphilid  and  suppurative  onychia  in  the  twenty-fifth  year 

(XVI) .90 

Infection  of  wife  after  nine  years  of  syphilis  and  four  years  of  marriage 

(Spillman)  (XVII) 94 

Interval  of  forty  years ;  then  tertiary  lesions  of  larynx,  nose,  tibia,  and 

frontal  bone  (XVIII) ■       .        .        98 

Interval  of  twenty  years;  then  tertiary  lesions  of  tibia,  ulna,  thigh, 

skin,  calf,  and  skull  (XIX) 99 

Relapses  of  secondary  lesions  for  twenty  years  and  of  tertiary  lesions 
(chancre  redux,  tongue  gumma,  tubercular  syphilid,  interstitial 
glossitis,  syphiloma  of  intestine)  from  the  fourth  to  the  twenty- 
fourth  years  (XX) 100 

Lost  palate  in  the  eighth  year;  interval  of  twenty-eight  j'^ears;  then 

tuberculo-ulcerative  syphilid  (XXI) 10 1 


XXVI  CASES   CITED 

PAGE 

Syphilis   and   epithelioma;   illustrating  the   difficulty   of   diagnosis 

(XXII) 113 

Syphilophobia  (XXIII) 114 

Syphilophobia  (XXIV) .        .        .115 

Chancre  not  followed  by  secondary  symptoms;  gumma  of  pharynx 

and  nasal  septum  after  six  years  (XXV) 116 

Cases  of  excessive  alcoholism  with  and  without  relapse  of  syphilis  .  130 
Case  of  excessive  smoking  without  relapse  of  mouth  lesions  .  .  131 
Case  illustrating  the  method  of  treating  an  obstinate  lesion       .         .160 

Note  on  the  treatment  of  Cases  IV  and  V 178 

Case  illustrating  the  virtue  of  insoluble  injections        .         .         .         .183 

Syphilis  untreated  three  years;  marriage,  healthy  child,  ulcers,  iodid 
three  years,  great  debility  and  lesions  only  partly  controlled, 
mercury,  marked  improvement,  iodid  resumed,  cure  (XXVI)    .      202 
Phagedenic  chancre  of  lip  (XXVII)    ...  ....      231 

Probable  Vincent's  angina  mistaken  for  chancre  (XXVIII)       .         .      250 
Probable  Vincent's  angina  mistaken  for  chancre  (XXIX)  .         .250 

Vincent's  angina  in  husband  and  wife  mistaken  for  chancre  (XXX)      250 
Example  of  the  blood  changes  in  early  syphilis,  and  the  effect  of 

treatment  upon  them         .         .         .         .         .         .         .         .         .256 

Toxemia  due  to  the  lesions  of  late  syphilis  (XXXI)    .         .         .         .268 

Early  syphilis  treated  briefly;  interval  of  twelve  years,  then  headache, 
sciatica,  and  lesions  of  cranium,  clavicles,  tibiae,  and  rib,  brief 
treatment.  Five  years  later  brief  left  hemiplegia ;  two  months 
later  right  monoplegia,  relapsing  a  month  later;  treatment  six 
months,  six  months  later  left  hemiplegia  (XXXII)  .  .  .  391 
Early  syphilis  treated  briefly ;  after  three  years  left  hemiplegia  and 
aphasia  followed  by  ulcers  and  periostitis  of  femur;  irregular 
treatment  and  relapses  of  ulcers  and  aphasia.  In  seventh  year 
coma  followed  by  mania,  almost  cured,  relapse  two  months  later 
of  coma  and  mania  with  right  hemiplegia,  then  epileptiform 

seizures  and  death  in  six  weeks  (XXXIII) 392 

Extragenital  chancre ;  prolonged  secondaries  and  treatment,  head- 
ache at  three  months,  left  hemiplegia  within  a  year,  ocular 
paralyses;  at  three  years  coma,  spontaneous  recovery,  healthy 
child ;  at  eleven  years  node  on  clavicle  ;  at  thirty  years  left  hemi- 
plegia, spontaneous  recovery  . 400 

Case  of  syphilitic  arthralgia  (XXXIV) 444 

Death  from  inhalation  of  detached  arytenoid  cartilage  (Labbe)  .  457 
Hepatic  syphilis  eluding  diagnosis  by  exploration  (Cumston)  (XXXV)     475 

Syphilitic  testicle  resembling  tuberculosis 480 

Instances  of  functional  tachycardia  occurring  during  syphilis  .  .485 
Cases  illustrating  the  differential  diagnosis  of  gummatous  adenitis  .  490 
Nephrectomy  for  sclero-gummatous  kidney  (Israel)  (XXXVI)  .      500 

Nephrectomy  for  sclero-gummatous  kidney  (Israel)  (XXXVII)  .  500 
Diffuse    pelvic    cellulitis    due    to     hereditary    syphilis    (Foumier) 

(XXXVIII) .- 502 


STATISTICS   AND    STATISTICAL   TABLES 


PAGE 

Age  at  onset  of  syphilis 58 

Aneurysm,  date  of  occurrence  of  (Etienne) 488 

proportion  of  syphilitic  (Etienne) 487 

rarity  of 487 

Ano-rectal  syphiloma,  rarity  of     .  494 

Aphasia,  frequency  of  and  lesions  with  which  associated      .         .         -395 

Appendicitis,  association  of  with  syphilis  (Gaucher) 494 

Army,  syphilis  in  (Surgeon  General's  report) 9 

venereal  diseases  in 3 

Bone,  bilateral  and  multiple  lesions  of     ......        ,   426 

occurrence  of  syphilis  of 425 

Bronchi,  rarity  of  syphilis  of      ...        .        .       ' 460 

Bursitis,  syphilitic        . "        .         .        .    449 

Chancre,  distribution  of  extragenital  (Bulkley,  Keyes)  .         .     ■    .      56 

extragenital,  and  sex .         -55 

multiple,  number  and  location  of 224 

overlooked,  how  often  is .         .82 

redux,  occurrence  of         .         .         .         .         .         .         .         .         .         .482 

relative  frequency  in  private  and  dispensary  practice  of  chancroid 

and 208 

urethral,  frequency  of 235 

Chancroid,  relative  frequency  of  in  private  and  dispensary  practice  of 

chancre  and 208 

Deafness,  association  of  with  other  syphilitic  lesions  of  the  nervous 

system •    .        .        .   395 

prognosis  of 396 

Early  lesions  overlooked 83 

Epilepsy,  frequency  of  syphilitic 398 

Epithelioma  and  leukoplakia 355 

Eye,  diplopia,  ptosis  and  vertigo  from  paralysis    of  the        .         .         .    387 
iritis,  frequency  of  (Terrien)  .         .         .         .         .         .         .        .         .411 

paralysis,  frequency  of    .         . 386 

Glycosuria,  frequency  of  among  syphilitics 492 

Heart,  rarity  of  syphilis  of  the 484 

Hereditary  syphilis,  frequency  of -67 

in  the  third  generation  (E.  Foumier) 77 

loss  of  weight  at  birth  in  (Tarnier)        .        .      • S°9 

xx\'n 


xx\dii  STATISTICS   AND    STATISTICAL   TABLES 

PAGE 

Hereditary  syphiLis,  occurrence  of  infantile  gummata  in  (Carpenter)  .    517 

occurrence  of  snuffles  in  (Hochsinger) 510 

prognosis  of  (Hyde) 539 

statistics  of  (Foumier,  Le  Pileur,  Hochsinger) 504 

Incubation,  duration  of,  experimentally  (Lang),  and  clinically   .         .81 

Infection,  frequency  of  extragenital 55" 

marital,  instant 61 

Infectiousness,  duration  of 61 

duration  of  maternal 67 

of  acquired  and  hereditary  syphilis  compared 68 

Insanity,  prognosis  of  syphiUtic  mania 399 

prognosis  of  syphilitic  dementia 402 

Joint  syphilis,  frequency  and  distribution  of  .         .         .         .         .         .    446 

Kidney  lesions,  frequency  of  in  post-mortem  examination  of  syphilit- 

ics  (Spiess) 497 

Larynx,  occurrence  of  syphilis  in 452 

Late  lesions,  incidence  and  distribution  of 104 

Leukoplakia,  distribution  of 352 

frequency  of  epitheUomatous  degeneration  in 355 

influence  of  tobacco  in  causing -350.  353 

Liver,  occurrence  of  syphiHs  in 469 

Lung,  rarity  of  sj'philis  of .-       .    460 

Mortality,  causes  of  death  (Gotha,  Bross) 136 

bv  years  elapsed  since  infection  (Gotha,  Bross)  ....    136 

life  insurance  statistics  of  (Blaschko,  Bross) 135 

Mouth  and  nasal  pharynx,  concurrence  of  lesions  about  the        .         -351 

onset  of  tertiaries  about 350 

relapses  about 350 

See  also  Leukoplakia. 

Muscle,  rarity  of  sj'philis  in 448 

Nervous  system,  syphilis  of,  date  of  onset  of 371 

etiology  of,  in  reference  to  sex,  age  treatment  and  alcoholism         .    369 

frequency  and  results  of 368 

hemiplegia  and  apoplexy  from 389 

paralysis  of  facial  nerve  due  to 397 

table  of  lesions  of 372 

See  also  Aphasia,  Deafness,  Eye,  Epilepsy,  Insanit}-,  Parasyphilids, 
Tabes. 

Nose,  tertiary  syphilis  of 364 

Palms  and  soles,  squamous  eruptions  on 303 

Parasyphilids,  relations  of,  with  syphiHs 108 

Paronychia,  occurrence  of  ...         • 3°9 

Prognosis  of  syphilis    .         .         .         - ^33 

controlled  by  observation  j-ears  after  cessation  of  symptoms  .         .    133 
See  also  Mortality. 

Secondary  lesions,  at  onset 86 

distribution  of  late 93 


STATISTICS    AND    STATISTICAL   TABLES  xxix 

PAGE 

Secondary  lesions,  duration  of 91 

occurrence  of  late     .         .         .         .         .         .         ...         .         .         -92 

occurrence  of  preemptive  febrile  toxemia 85 

occurrence  of  rarer 87 

Tabes,  frequency  of 43 

Tendons,  rarity  of  sj^philis  of  the 449 

Teno-synovitis,  rarity  of  syphilitic 451 

Tertiary  lesions,  distribution  of 104 

duration  of,  in  alcoholics         . 103 

duration  of,  in  well-treated  and  in  ill-treated  cases    .         .         .         .102 

frequency  of      .... 96 

incidence  of  (Foumier,  Keyes) 96 

relapses  of,  frequency  of 97 

relapses  of,  intervals  between 98 

Spirocheta  pallida,  distribution  of 27 

Treatment,  improvement  of,  in  late  years 42 

Woman,  early  lesions  mild  in      . 45 

extragenital  infection  common  in 55 

extragenital  infection,  table  showing 56 

lesions  at  onset  of  syphilis  in 86 

marital  infection  of           . 61 

occurrence  of  rarer  secondary  lesions  in 87 

parasyphilids  rare  in 45 


SYPHILIS 


CHAPTER    I 

SYPHILIS  IN  RELATION  TO  PUBLIC  HEALTH 

■  Some  fifteen  years  ago  there  appeared  for  the  first  time 
in  America  a  book  on  syphiHs/  the  last  chapter  of  which 
bore  the  above  title.  Fifteen  years  ago  the  science  of  pre- 
ventive medicine  was  in  its  infancy  and  venereal  sociology 
did  not  exist.  Yet  Dr.  Armstrong  then  said :  "  The  rela- 
tion that  any  disease  bears  to  the  public  health  is  in  a  direct 
ratio  to  its  prevalence  and  its  preventability." 

In  the  intervening  years  evidence  of  the  appalling  preva- 
lence of  syphilis  has  been  accumulating  with  ever-increasing 
force;  and  if  evidence  of  its  preventability  is  lacking,  this  is 
due  to  the  prudishness  of  our  morality,  the  inherent  slug- 
gishness of  public  opinion,  and  in  no  small  degree  to  the 
unwillingness  of  medical  men  to  take  their  part  in  the  crusade. 

But  at  last  we  begin  to  see  light.  The  International  Soci- 
ety of  Sanitary  and  Moral  Prophylaxis,  with  its  national  and 
local  branches,  is  the  first  fruit  of  an  awakened  public  appre- 
ciation that  there  is  work  to  be  done  in  the  prevention  of 
social  diseases  in  general  and  of  syphilis  in  particular.  Thus 
this  question  of  the  prevalence  and  the  preventability  of  syphi- 
lis, which  formed  an  almost  surreptitious  last  chapter  a 
decade  and  a  half  ago,  now  very  properly  usurps  the  initial 
position  so  long  held  by  fruitless  disquisitions  on  the  history 
of  syphilis — discjuisitions  as   intimate  to  the  practical   study 

'Morrow's  "System," 


2  SYPHILIS    IN    RELATION   TO    PUBLIC   HEALTH 

of  the  disease  as  a  lecture  on  colonial  architecture  when  the 
townhall  is  afire. 

The  three  important  points  to  be  considered  are  the  preva- 
lence of  syphilis,  the  effect  of  syphilis  upon  the  community 
(syphilis  and  marriage),  and  the  prevention  of  syphilis. 

THE  PREVALENCE  OF  SYPHILIS 

The  prevalence  of  gonorrhea  is  generally  accepted.  The 
current  statement  that  some  sixty  to  eighty  per  cent  of  young 
unmarried  men  suffer,  at  one  time  or  another,  from  it  has 
almost  ceased  to  evoke  comment.  Gynecologists  have  come 
to  agree  that  sixty  to  eighty  per  cent  of  pelvic  suppurations 
requiring  hysterectomy  or  oophorectomy  are  due  to  gonor- 
rhea, and  to  recognize  that  no  class  of  society  is  spared  by 
this  terrible  scourge.  But  the  public  mind  is  not  yet  enlight- 
ened concerning  syphilis.  This  disease  is  considered  so  dis- 
figuring that  people  will  not  realize  how  their  fellows,  whom 
they  see  daily  bright-eyed  and  clear-skinned  mingling  with 
the  rest  of  mankind,  can  yet  be  syphilitics.  Tell  the  man  in 
the  street  that  some  ten  per  cent  of  the  inhabitants  of  Berlin 
or  Paris  are  syphilitic,  and  he  will  see  visions  of  poverty  and 
filth ;  he  will  not  believe  that  the  upper  classes  form  an  appre- 
ciable proportion  of  the  sufferers.  Although  we  recognize 
that  many  men  of  the  higher  class  have  gonorrhea  at  least 
once  in  their  lives,  we  must,  nevertheless,  concede  that  they 
acquire  the  disease  much  less  frequently  and  suffer  from  it 
far  less  intensely  than  do  the  lower  classes.  The  same  is  true 
of  syphilis.  It,  undoubtedly,  strikes  less  frequently  and  less 
sharply  the  man  protected  by  wealth  and  position  than  the 
grimy  slave  of  toil.  Yet  no  one  is  immune.  Among  our 
office  records,  which  go  back  half  a  century,  I  find  the  pro- 
portion of  syphilitics  to  gonorrheics  varies  from  i-8  to  i-i5> 
and  this  I  take  to  be  not  far  from  the  true  proportion  among 


THE   PREVALENCE  OP   SYPHILIS  3 

the  middle  and  upper  classes  of  men  in  New  York  City.  Four- 
nier  is,  if  anything,  more  pessimistic  in  his  oft-quoted  state- 
ment that,  among  the  syphilitic  women  who  come  to  his  office, 
one  in  five  is  a  wife  infected  by  her  husband. 

Perhaps  as  good  evidence  as  can  be  obtained  of  the  influ- 
ence of  social  position  in  determining  the  incidence  of  syphilis 
is  that  afforded  by  the  Report  of  the  Surgeon  General  of  the 
Army.^  In  1904  the  proportion  of  syphilitics  among  the  en- 
listed men  (white)  was  27.83  per  mille;  among  the  officers, 
2.78  per  mille  (just  one  tenth).  The  ratio  of  syphilis  to 
gonorrhea  among  the  men  was  1-4;  among  the  officers,  i-i ; 
among  the  negroes,  1—6;  the  incidence  of  syphilis,  per  mille 
per  annum,  being  among  the  white  men,  35.11;  officers,  3.51; 
colored  men,  13.78.^ 

This  same  report  shows  the  prevalence  of  venereal  dis- 
eases very  strikingly.  "  By  far  the  most  important  diseases 
affecting  the  efficiency  of  the  army  during  the  year  have  been 
the  venereal  .  .  .  causing  sixteen  per  cent  of  all  admissions, 
twenty-eight  per  cent  of  all  non-effectiveness,  and  eighteen 
per  cent  of  all  discharges  for  diseases." 

The  number  of  syphilitics  treated  during  the  year  1904 
was  1,996,  and  the  disease  stands  fifth  on  the  list,  preceded 
by  gonorrhea  (7,106),  malaria  (3,953),  bronchitis  (3,091), 
influenza  (2,485),  and  closely  followed  by  chancroid  (1,961) 
and  alcoholism  (1,498). 

But  if  we  measure  the  importance  of  a  disease  by  the  dam- 
age it  does,  syphilis  immediately  jumps  into  far  greater  promi- 
nence. Taking  as  a  criterion  the  "  number  of  days  sick,"  we 
find  syphilis  with  70,398  days  second  only  to  gonorrhea  with 


1  The  venereal  statistics  of  the  navy  are  bound  always  to  be  singularly  bad 
on  account  of  abnormal  social  conditions. 

2  It  may  be  noted  that  the  two  chief  causes  for  rejection  of  recruits  were, 
per  mille,  for  whites,  defect  of  development,  120.08;  venereal  diseases,  100.46; 
for  colored,  venereal  diseases,  170.78;  defect  of  development,  98.68. 

3 


4  SYPHILIS    IN    RELATION   TO    PUBLIC   HEALTH 

146,609,  and  well  ahead  of  dysentery  (49,518)  and  tubercu- 
losis (49,195).  Although  only  responsible  for  2  out  of  233 
deaths  from  disease  that  occurred  during  the  year  1904,  syphi- 
lis stands  first  of  all  as  a  destroyer  of  careers,  causing  166 
discharges  (2.76  per  mille),  whereas  tuberculosis  caused  only 
loi.  This  fact  alone  would  be  enough  to  mark  syphilis  as 
one  of  the  great  scourges  of  the  human  race.  There  are  more 
soldiers  rendered  permanently  unfit  to  follow  their  profession 
by  syphilis  than  by  any  other  disease. 

SYPHILIS    AND   MARRIAGE 

The  very  importance  of  syphilis  in  the  army  is  enough 
to  condemn  it  in  certain  minds  to  classification  as  a  righteous 
punishment  for  defiance  of  the  moral  law.  Yet  this  is  pre- 
cisely not  the  case.  The  syphilitic  is  a  constant  menace  to 
his  fellows,  whom  he  may  infect  accidentally  at  any  moment; 
and  this  danger  is  greatest  to  those  nearest  and  dearest  to 
him,  to  his  mother  or  sister  and,  above  all,  to  the  wife  he 
marries  and  the  children  he  begets.  Any  syphilologist  can 
cap  the  following '  incidents  that  have  come  under  my  obser- 
vation : 

Case  I. — A  young  and  upright  man  kisses  a  girl  at  an  even- 
ing frolic.  Shortly  after  he  becomes  engaged  to  marry  another 
girl.  A  supposed  fever  sore  upon  his  lip  causes  him  no  anxiety 
until  a  similar  sore  appears  upon  the  eyelid  of  his  betrothed  and 
an  eruption  breaks  out  upon  his  own  body.  Then  to  the  family 
physician,  who  finds  both  syphilitic. 

Case  II. — A  man  acquires  a  chancre  upon  the  lip  in  some 
way  to  him  unknown.  His  malady  runs  a  very  mild  course,  and 
he  consults  no  physician,  remains  ignorant  of  the  nature  of  his 
disease,  and  soon  marries.  A  year  later  a  child  is  born  at  term, 
but  dies  in  ten  weeks  of  syphilis.  A  second  child  dies  at  three 
years  of  age,  also  syphilitic.  Meanwhile  the  husband,  who  has 
had  nodes  on  his  skull  and  cerebral  symptoms,  has  undergone  a 
mild  course   of  treatment,   just  enough   to   cure  his   symptoms. 


SYPHILIS   AND    MARRIAGE  5 

Then  the  mother,  who  has  never  shown  any  sign  of  syphiHs, 
becomes  pregnant  again.  She'  is  put  on  mercury  dviring  gesta- 
tion, and  bears  a  healthy  child.  When  this  child  is  two  and 
one  half  years  old,  five  years  after  infection,  the  mother  shows 
the  first  sign  of  the  disease,  a  naso-pharyngeal  ulceration  that 
carries  away  some  of  her  septum  and  continues  for  seven  years, 
during  which  time  she  is  pretty  constantly  under  treatment  and 
bears  another  healthy  child.  Meanwhile  the  husband  has  necrosis 
of  his  septum,  submits  to  treatment  for  three  years,  and  remains 
well  when  last  seen,  eleven  years  after  the  cessation  of  treat- 
ment and  twenty-eight  years  after  the  beginning  of  the  disease. 
Not  so  the  wife;  she  continues  to  bear  healthy  children,  and 
remains  well  from  the  twelfth  to  the  twentieth  year  of  her  dis- 
ease. Then  it  attacks  the  tibiae,  the  heart,  the  frontal  bone,  the 
thumb.  Five  years  later  what  there  is  left  of  her  no  longer 
shows  active  symptoms  of  syphilis. 

Nor  is  this  all.  Even  before  the  first  child  died,  its  mother's 
milk  gave  out,  and  her  sister,  who  was  nursing  her  own  child 
and  had  milk  to  spare,  offered  to  take  the  infant  until  a  wet- 
nurse  could  be  obtained.  She  nursed  it  ten  days.  In  a  few 
weeks  her  nipple  got  quite  sore,  and  later  she  had  a  little  sore 
throat.  She  took  no  treatment,  and  infected  her  child,  but  not 
her  husband.  Her  next  child  was  born  syphilitic,  but,  happily, 
was  cured  by  treatment.  She  then  took  treatment,  bore  a  healthy 
child  three  years  after  infection,  and  had  no  further  symptoms 
herself. 

Here,  then,  is  syphilis  innocently  acquired  by  a  citizen  of 
the  highest  class.  Before  he  discovers  its  nature  he  bestows 
upon  his  wife  a  disease  which  pursues  her  for  a  quarter  of 
a  century  and  leaves  her  disfigured  and  shattered,  which  kills 
two  of  her  infants  and  one  of  her  sister's.  In  sum,  three 
deaths,  at  least  one  life  ruined,  and  sickness  and  misery  to 
four  who  did  not  die. 

Such  is  syphilis  insontium — syphilis  of  the  innocent. 
These  cases  have  been  selected  rather  because  they  represent 
an  infection  acquired  innocently  than  for  any  other  reason. 
Similar  ones  are  common  enough,  and  among  the  ignorant 


6  SYPHILIS    IN    RELATION   TO    PUBLIC    HEALTH 

and  impoverished  widespread  epidemics  thus  arise.  Of  the 
infections  spread  by  midwives,  by  physicians,  by  dentists, 
there  is  no  end.  I  have  known  an  innocent  wife  to  put  her 
syphilitic  infant  to  the  breast  of  an  equally  innocent  wetnurse, 
and  when  this  woman  became  infected  to  drive  her  from  the 
house  and  supplant  her  by  another  victim,  who  was  infected 
in  turn  ere  the  mother  learned  the  horror  of  the  true  situation. 

And  this  is  the  unspeakable  disease  which  the  public  will 
not  hear  named,  much  less  publicly  attacked.  Truly  the  won- 
der is  that  syphilis  insontium  is  so  rare. 

But  it  is  rare,  relatively  speaking.  It  does  not  call  for 
hysterical  syphilophobia.  It  can  be  cured.  Its  transmission 
to  the  next  generation  can  be  prevented.  The  individual  treat- 
ment of  syphilis  is  well  understood  in  our  day.  But  its 
prophylaxis  we  are  only  beginning  to  study. 

THE   PROPHYLAXIS   OF  SYPHILIS 

Individual  prophylaxis  is  futile.  As  long  as  men  indulge 
in  illicit  sexual  intercourse,  so  long  will  syphilis  exist.  There 
is  no  preventing  it.  The  condom  is  to-day,  as  it  was  in  the 
time  of  Ricord,  "  a  cuirass  against  pleasure  and  a  cobweb 
against  danger."  Antiseptic  washes  have  yet  to  prove  their 
protective  powers.  Even  cauterization  of  a  torn  f renum  within 
six  hours  of  the  time  of  infection  has  twice  (Hill,  Ruggles) 
failed  to  prevent  the  subsequent  appearance  of  syphilis  (cf. 
page  32). 

Yet  many  of  our  most  aristocratic  brethren  insist  that  they 
do  not  haunt  the  dens  where  such  diseases  fester.  They  fancy 
that  high  price  purchases  immunity.  No  fancy  could  be  more 
fallacious.  A  contemplation  of  the  cases  just  recited  may 
serve  to  impress  the  truth  that  it  is  possible  to  transmit  the 
disease  before  you  know  you  have  it.  And  she  who  is  kind 
to  one  may  perhaps  be  generous  to  twenty  in  his  absence. 


THE    PROPHYLAXIS    QF    SYPHILIS  7 

In  short,  there  is  no  individual  prevention  of  syphilis.  To 
control  this  disease  it  must  be  attacked  as  a  plague. 

Naturally,  the  first  attempts  at  control  have  been  directed 
against  the  prostitute.  "  Here  is  the  causa  tctcrrima ;  let  us 
wipe  it  out."  And  since  prostitution  refuses  to  be  eradicated 
from  any  large  community,  the  effort  has  been  made  to  con- 
trol it,  and  war  has  waged  for  many  years  between  the  advo- 
cates of  licensed  prostitution  and  the  purists  who  have  been 
described  in  delightful  mixed  metaphor  as  "  closing  one  eye 
to  the  existence  of  prostitution  while  trying  to  stamp  it  out 
with  the  other." 

Up  to  the  present  our  Puritan  blood  has  kept  us  Americans 
from  considering  the  subject  sanely.  We  still  cling  blindly 
to  the  theory  that  prostitution  may  be  suppressed,  though  the 
history  of  every  century  and  every  country  proclaims  that  it 
never  has  been. 

On  the  other  hand,  the  adherents  of  reglementation  are 
little  better  off.  They  find  that,  at  the  expense  of  much  effort, 
time,  and  money,  they  can  show  no  appreciable  improvement 
in  morals,  no  marked  decrease  in  the  incidence  of  venereal 
disease.^     The  causes  of  their  failure  are  chiefly  three. 

First,  they  attack  venereal  disease,  yet  make  no  effort  to 
improve  the  morals  of  the  community,  and  so  leave  untouched 
the  foremost  of  its  causes. 

Secondly,  they  examine  the  prostitute  at  most  once  a  week, 
present  her  with  a  certificate  of  cleanliness;  and,  before  she 
returns,  she  will  (according  to  Parisian  statistics)  have  cohab- 
ited with  from  three  to  five  men  a  day.  So  that  (accepting 
the  infallibility  of  the  hasty  and  routine  examination)  she  has, 
toward  the  end  of  the  week,  risked  contamination  from  twenty 
to  thirty  times.  Manifestly  such  an  assurance  of  cleanliness 
is  not  overeffective. 

'  Cf.  the  Report  of  the  New  York  Committee  of  Fifteen,  published  under 
the  title,  "The  Social  Evil,"  by  G.  P.  Putnam's  Sons. 


8  SYPHILIS    IN    RELATION   TO    PUBLIC   HEALTH 

Thirdly,  venereal  disease  can  never  be  stamped  out  by  the 
inspection  of  licensed  prostitutes  so  long  as  unlicensed  prosti- 
tution remains  unsuppressed  (and  who  shall  suppress  it?)  and 
so  long  as  the  men  are  not  examined  as  well  as  the  women. 
Would  the  suppression  of  tuberculosis  be  taken  seriously  if 
only  the  tuberculous  women  were  reported  while  the  men  were 
allowed  to  go  scot-free? 

The  problem  is  a  difficult  one,  and  the  solution  is  not  yet ; 
but,  recognizing  the  prevalence  of  syphilis  and  of  gonorrhea 
as-  well  as  the  destruction  of  life  and  happiness  they  cause, 
it  is  surely  essential  that  we,  as  medical  men,  should  gravely 
consider  not  only  the  methods  of  their  cure,  but  also  the  means 
of  prophylaxis.  These  means  are  now  being  intelligently  dis- 
cussed throughout  the  country,  especially  in  the  various 
branches  of  the  Society  of  Sanitary  and  Moral  Prophylaxis. 

The  few  fundamental  principles  that  have  been  generally 
accepted  may  be  summed  up  as  follows : 

1.  Absolute  continence  does  not,  in  man  or  in  woman,  im- 
pair sexual  instinct  or  appetite,  nor  does  it  diminish  the  pro- 
creative  power.  Moreover,  the  effect  of  continence  upon  the 
general  health  is  highly  beneficial. 

2.  Apparent  exceptions  to  this  rule,  cases  of  general  or  of 
sexual  neurasthenia,  impotence,  etc.,  occurring  in  persons  who 
do  not  run  to  sexual  excess,  may  always,  on  intimate  inves- 
tigation, be  attributed  to  one  of  three  causes :  commonly  to 
some  concealed  secret  vice,  less  frequently  to  mental  incon- 
tinence (the  most  degrading  of  all  forms  of  incontinence  in 
that  it  prostitutes  the  mind  to  constant  contemplation  of  vicious 
subjects  while  covering  this  inward  rottenness  with  an  out- 
ward veneer  of  physical  cleanliness),  and  rarely  to  systemic 
abnormality  or  disease. 

3.  Conversely,  sexual  immorality  of  any  sort,  besides  tend- 
ing to  disseminate  venereal  disease,  lowers  the  morals  and 
assails  the  general  health;  for 


THE    PROPHYLAXIS   OF   SYPHILIS  9 

4.  Sexual  intercourse,  though  undeniably  productive  of  a 
sense  of  physical  well-being  which  renders  it  desired  by  all 
men  and  essential  to  many  (once  the  habit  is  formed),  is  not 
comparable  to  such  physiological  needs  as  breathing  air  and 
eating  food,  but  rather  to  smoking  and  drinking  alcohol. 
Note,  for  example,  that  it  is  a  pleasure  which  becomes  a  neces- 
sity only  from  the  same  intemperate  indulgence  that  makes 
alcohol  or  tobacco  a  necessity.  Note,  also,  that  the  hold  it 
gets  on  most  men  more  closely  resembles  the  morphin  or  cocain 
habit  than  the  milder  intoxications  of  alcohol  and  tobacco; 
hence  the  only  hope  of  physical  purity  for  most  men  lies  in 
avoiding  the  Urst  misstep. 

5.  Consequently  the  most  important  prophylactic  measure 
is  the  protection  of  childhood;  not  the  futile  protection  of  as- 
sumed ignorance,  but  the  protection  of  intelligent  instruction 
from  a  respected  source,  individual  (parental,  if  possible)  at 
first,  perhaps  collective  later  (not  by  books  or  tracts),  and 
advancing  in  accord  with  the  awakening  instincts  of  the  indi- 
vidual. 

6.  Moreover,  it  is  the  paramount  duty  of  the  physician  to 
instruct  every  patient  treated  for  venereal  disease  concerning 
the  grave  dangers  of  infection,  especially  in  matrimony. 

Such  are  some  of  the  fundamental  moral  principles  upon 
which  the  prophylaxis  of  syphilis  must  be  founded.  The 
application  of  these  principles  to  the  needs  of  children,  of  fac- 
tory and  shop  girls,  of  the  army  and  navy ;  the  passage  of  laws 
requiring  that  venereal  diseases  be  classified  as  infectious  and 
reported  to  the  board  of  health ;  the  provision  of  adequate  hos- 
pital facilities  for  venereal  cases  in  place  of  the  present  refusal 
of  hospitals  to  accept  them ;  the  renewal  of  the  army  canteen, 
the  withdrawal  of  which  has  been  followed  by  a  progressive 
increase  in  venereal  disease ;  ^  such  practical  matters  we  may 

» The  incidence  of  syphilis  is  highest  in  the  English  army  (75  per  mille, 
per  annum).     Then  follow  the  United  States  (33.98),  Austria  (19.2),  Russia 


lO  SYPHILIS    IN    RELATION   TO    PUBLIC   HEALTH 

hope  to  see  thoroughly  thrashed  out  in  the  future.  In  the 
meanwhile  it  is  our  duty  to  present  the  facts  to  the  laity  and 
to  animate  discussion  among  them,  while  protecting  to  the 
best  of  our  ability  the  innocent  wives  and  children  of  our 
venereal  patients. 

(12.8),  France  (6.7),  Holland  (4.9),  Bavaria  (4.3),  Prussia  (4.0).  The  prudish 
Anglo-Saxon  refusal  to  countenance  protective  measures  for  the  health  of  the 
army  here  shows  its  results. 


CHAPTER    II 
THE  GENERAL  CHARACTERISTICS  OF  SYPHILIS 

Syphilis  (the  pox)  is  an  infectious  disease,  probably 
caused  by  the  Spirocheta  pallida.  It  is  acquired  by  contagion 
or  by  heredity;  it  is  chronic  in  course,  indefinite  in  duration, 
essentially  intermittent  in  character,  manifesting  itself  by  a 
succession  of  lesions  which  may  involve  any  part  of  the  body, 
and  which  are  arbitrarily  classified  as  primary,  secondary,  ter- 
tiary, and  parasyphilitic.^ 

Syphilis  is  as  varied  in  character  as  it  is  widespread  in 
distribution.  No  country  in  the  world,  no  organ  in  the  body 
is  exempt  from  its  taint.  In  the  detailed  description  of  the 
disease  there  is  some  danger  of  losing  amid  a  maze  of  minutiae 
the  main  thread  of  the  story ;  hence  the  need  of  a  preliminary 
resume.  The  ability  to  distinguish  forty  different  syphilides, 
though  it  may  permit  an  occasional  brilliant  diagnosis,  is 
scarcely  essential  to  a  true  knowledge  of  syphilis.  For  syphi- 
lis, whatever  else  it  may  be,  is  not  a  skin  disease.  The  skin 
lesions  of  syphilis  are  as  common  and  obvious  as  the  foaming 
crest  of  an  ocean  wave,  and,  like  it,  they  are  but  the  outward 
and  relatively  insignificant  manifestations  of  forces  which 
human  science  has  not  yet  measured.  Syphilis  is  an  infection 
of  the  whole  man  which,  for  intensity  and  pertinacity,  has  no 
rival  but  tuberculosis  and  leprosy.  It  shortens  more  lives  than 
we  can  estimate,  and  its  ultimate  ravages  are  not  yet  known. 


'The  classification  of  late  sclerotic  lesions  (e.  g.,  tabes,  paresis,  aortitis), 
as  quaternary  has  been  suggested,  but  is  not  generally  accepted. 

It 


12        THE    GENERAL    CHARACTERISTICS    OF    SYPHILIS 

HISTORY   OF   SYPHILIS 

Until  the  year  1494  syphilis,  as  we  know  it  to-day,  did 
not  exist.  Doubtless  it  was  known  to  the  Chinese,  and  per- 
haps it  was  imported  into  Europe  by  Columbus's  returning 
squadron;  the  evidence  for  and  against  is  conflicting  and  in- 
conclusive. But  this  we  know :  modern  syphilis  was  first  rec- 
ognized in  the  last  decade  of  the  fifteenth  century,  beginning 
among  the  soldiers  of  Charles  VIII,  King  of  France,  in  his 
campaign  against  Naples.  Whether  the  disease  was,  as  an 
ancient  chronicler  shrewdly  guesses,  "  non  nova  simpliciter, 
sed  nobis  tantiim,"'  matters  little.  It  spread  rapidly  over  Eu- 
rope, infecting  every  grade  of  society  from  king  to  peasant, 
and  execrated  as  the  morbus  Galliciis,  because  of  its  supposed 
origin  in  the  French  army  before  Naples.  The  French  them- 
selves entitled  it  more  gracefully  sonvcnir  de  Naples,  and  it 
flourished  impartially  in  many  lands  under  a  variety  of  names. 

Whether  the  modern  name  of  the  disease  means  "  with  a 
girl  "  {(Tvv  (f)i\la),  or  "  friend  of  a  pig"  (o-u^  ^1X09)  depends 
upon  one's  point  of  view.  At  all  events  it  was  first  bestowed 
by  Frascatori  (1483-1553)  upon  the  mythical  pater  syphi- 
liticorum,  hero  of  a  metrical  venereal  romance. 

But  no  sooner  did  syphilis  force  itself  upon  the  notice  of 
physicians  than  they  promptly  confused  it  with  gonorrhea  and 
chancroid,  regarding  the  three  as  different  manifestations  of 
the  same  disease.  All  doubts  as  to  the  unity  of  this  venereal 
Cerberus  were  quieted  for  nearly  a  century  by  John  Hunter, 
who,  in  1767,  inoculated  gonorrheal  pus  on  the  glans  and  fore- 
skin (whether  his  own  or  another's  he  does  not  state,  though 
tradition  makes  him  the  martyr)  and  produced  syphilis.  The 
inference  is  obvious :  this  "  gonorrheal  "  pus  was  syphilitic ; 
perhaps  both  syphilitic  and  gonorrheal.  But  the  inference 
drawn  by  Hunter  and  accepted  by  the  world  at  large  was  that 
gonorrhea,   syphilis,   and  chancroid  were  one  and  the  same. 


ACQUIRED    SYPHILIS  I3 

which  error,  matched  curiously  with  the  accurate  description 
of  what  has  since  been  known  as  the  Hunterian  chancre,  has 
spread  John  Hunter's  name  farther  than  the  conscientious 
labors  that  made  him  the  father  of  English  surgery. 

The  next — perhaps  one  might  say  the  first — great  name  in 
the  history  of  syphilis  is  Philippe  Ricord.  Born  in  Baltimore, 
December  10,  1800,  Ricord  carried  out  his  lifework  at  Paris. 
He  proved  that  gonorrhea  and  syphilis  were  distinct  diseases, 
enunciated  the  theory  of  primary,  secondary,  and  tertiary  syphi- 
lis upon  which  the  modern  study  of  the  malady  is  based,  and 
cleared  the  way  for  Bassereau's  distinction  between  true  chan- 
cre and  chancroid. 

For  fifty  years  more  "  unalists  "  and  "  dualists  "  fought  it 
out,  with  the  believers  in  "  syphilization  "  (i.e.,  prophylactic 
inoculation  against  syphilis  with  chancroidal  pus)  inoculating 
themselves  daily  in  the  vain  hope  of  producing  immunity.  But 
gradually  the  dualists  gained  ground  until  the  advent  of  bac- 
teriology and  the  successive  discoveries  of  the  gonococcus  and 
the  bacillus  of  chancroid  have  swept  away  the  last  vestige  of 
hope  that  gonorrhea,  syphilis,  and  chancroid  can  ever  again 
pose  as  one  and  the  same  disease. 

Such,  briefly,  is  the  history  of  our  knowledge  of  syphilis. 
The  more  recent  developments  will  be  dwelt  upon  each  in  its 
appropriate  place  in  our  study  of  the  disease. 

ACQUIRED   SYPHILIS 

Syphilis  is  a  contagious  disease  whose  general  character- 
istics are  best  studied  in  its  "  acquired  "  form.  The  peculiar- 
ities of  hereditary  syphilis  may  be  subsequently  discussed. 

The  disease  may  be  acquired  only  by  contact  with  a  syphil- 
itic sore  or  with  some  substance  upon  which  the  secretion  of 
a  syphilitic  lesion  has  been  recently  deposited.  The  infection, 
does  not  travel  in  the  air,  nor  do  rooms  occupied  by  syphilitics 


14 


THE    GENERAL   CHARACTERISTICS   OF    SYPHILIS 


become  infected.  Moreover,  the  virus  is  probably  incapable  of 
piercing  the  intact  integument. 

The  Primary  Lesion. — Acquired  syphilis  always  begins, 
after  a  few  weeks'  incubation,  with  an  eroded  papule  at  the 
point  of  inoculation.  This  lesion  is  called  chancre,  and  is  ac- 
companied by  a  characteristic  inflammation  in  the  adjacent 
lymph  glands.  This  chancre  and  adenitis  constitute  the  pri- 
mary lesion. 

The  Secondary  Lesions. — A  few  weeks  later  the  secondary 
lesions  appear.  These  consist  of  typical  exanthemata  upon  the 
skin  and  mucous  membranes,  acute  inflammations  of  certain 
organs  (iritis,  periostitis,  etc.),  and  evidences  of  general  in- 
fection. The  toxemia  is  often  very  light  and  generally  lasts 
but  a  few  weeks,  while  the  localized  secondary  lesions  have  a 
tendency  to  relapse,  after  intervals  of  apparent  health,  for  at 
least  two  years.  These  localized  secondary  lesions  are  in- 
fectious, superficial,  and  benign  (i.  e.,  tending  to  sponta- 
neous cure  and,  generally  speaking,  not  destructive  of  tissue 
nor  productive  of  a  permanent  scar). 

The  Tertiary  Lesions. — The  tertiary  lesions  of  syphilis 
may  occur  at  any  time  after  the  appearance  of  the  chancre. 
They  may  relapse  after  an  interval  of  years.  They  rarely 
appear  until  after  the  first  outbreak  of  secondary  lesions  has 
spent  itself.  In  contrast  to  the  secondary  lesions  they  are  clin- 
ically not  infectious  (page  36),  are  deep  rather  than  super- 
ficial in  location  and  malignant  in  that  they  destroy  tissue 
and  show  little  or  no  tendency  to  spontaneous  cure.  Moreover, 
they  bear  no  special  affinity  to  the  skin,  but  impartially  attack 
every  organ.  Histologically  the  tertiary  lesion  is  either  a 
specific  syphilitic  granuloma  (gumma)  or  a  dififuse  interstitial 
sclerosis. 

The  Parasyphilides. — Finally,  there  is  a  class  of  lesions, 
partially  syphilitic  in  character,  termed  by  Fournier  the  para- 
syphilides.    These  lesions  occur  usually  in  persons  who  have 


ACQUIRED    SYPHILIS  15 

had  syphilis,  but  after  the  other  syphilitic  lesions  have 
ceased  to  appear.  Yet  they  also  occur  in  persons  who  are  not 
apparently  syphilitic ;  they  are  often  entirely  unmanageable  by 
mercury  and  iodides  (the  antisyphilitic  specifics)  and,  even 
when  occurring  in  syphilitics,  they  are  habitually  in  part  due  to 
other  causes. 

Thus  the  exact  nature  of  the  parasyphilides  is  not  clear. 
Some  of  them,  such  as  tabes,  are  almost  exclusively  due  to 
syphilis;  others,  such  as  arterial  sclerosis,  are  far  from  being 
exclusively  syphilitic ;  while  in  all,  the  absence  of  lesions 
pathologically  syphilitic  as  well  as  the  resistance  to  antisyphil- 
itic treatment  render  a  decision  still  more  doubtful. 

Are  there  Periods  of  Syphilis  ? — The  importance  of  these 
various  syphilitic  lesions  to  the  patient  varies  inversely  with 
their  influence  upon  the  community.  The  primary  and  sec- 
ondary lesions  are  rarely  sufficiently  grave  to  be  a  serious  in- 
convenience to  the  patient ;  yet  they  are  actively  infectious  and 
a  constant  menace  to  the  public  health.  The  destructive,  ma- 
lignant tertiary  lesions,  on  the  other  hand,  are  clinically  not 
infectious,  but  may  gravely  disable  their  host ;  while  the  para- 
syphilides are  even  more  evil  in  prognosis  as  far  as  the  indi- 
vidual is  concerned. 

Happily,  however,  the  tertiary  syphilides  may  be  prevented, 
or  at  least  much  ameliorated,  by  proper  early  treatment  and 
the  parasyphilides  avoided  by  intelligent  hygiene. 

Finally,  note  that  the  above  classification  is  an  arbitrary 
one.  The  primary  lesion  is  definite  and  immutable  (though 
it  may  be  overlooked),  but  beyond  this  all  is  variable.  Sec- 
ondary lesions  may  be  so  mild  as  to  pass  unnoticed.  Tertiary 
lesions  may  never  occur,  or  they  may  appear  before  the  sec- 
ondary, or  the  two  may  exist  side  by  side ;  or,  more  confusing 
still,  a  given  lesion  may  be  on  the  border  line,  perhaps  sec- 
ondary, perhaps  tertiary ;  and  a  superficial  lesion,  apparently 
secondary  at  first,  may  later  develop  the  characteristics  of  ter- 


l6        THE    GENERAL   CHARACTERISTICS   OF    SYPHILIS 

tiarism.      Moreover,   parasyphilitic  lesions  may  coexist  with 
tertiary  manifestations. 

Hence  there  is  no  such  thing  as  a  purely  secondary  or  ter- 
tiary period  of  the  disease.  Secondary  symptoms;  yes.  Ter- 
tiary symptoms ;  yes.  Periods ;  no.  The  terms  secondary  and 
tertiary  are  conventional  symbols  to  express  the  quality  of  cer- 
tain symptoms.  It  is  utterly  misleading  to  apply  them  to  peri- 
ods of  time  when  these  periods  so  overlap  as  to  produce  con- 
fusion from  the  use  of  terms  whose  only  purpose  is  to  prevent 
confusion. 

HEREDITARY   SYPHILIS 

The  worst  horror  of  syphilis  is  the  fear  of  passing  it  on  to 
generations  as  yet  unborn.  For  syphilis  may  be  transmitted 
by  inheritance  from  a  syphilitic  parent. 

The  laws  that  govern  the  inheritance  of  syphilis  are  not 
well  understood,  lacking  as  they  do  any  scientific  control  and 
depending  entirely  upon  clinical  facts. 

A  syphilitic  father  may  beget  a  syphilitic  child  without 
apparently  infecting  the  mother ;  yet  this  mother  cannot  be  in- 
fected with  syphilis  by  nursing  the  child  (Colles's  law),  al- 
though the  child  will  promptly  infect  any  other  wetnurse. 
Moreover,  the  mother  of  such  a  syphilitic  child,  though  herself 
remaining  healthy  many  years,  almost  invariably  ultimately 
breaks  out  with  tertiary  syphilis  {choc  en  retour).  Manifestly, 
therefore,  the  mother  of  a  syphilitic  child,  even  though  she 
remain  apparently  sound,  is  in  some  way  or  in  some  degree 
syphilitic. 

The  danger  of  transmission  from  father  to  child  ceases  in 
from  two  to  five  years  if  the  father  is  properly  treated.  Under 
inefficient  treatment  paternal  virulence  may  last  indefinitely, 
though  it  is  likely  to  terminate  within  five  years  in  any  case. 

The  danger  of  transmission  from  mother  to  child  does  not, 
however,  terminate  at  any  definite  time.     Some  mothers  con- 


HEREDITARY    SYPHILIS  17 

tinue  to  bear  syphilitic  children  for  years  after  the  disappear- 
ance of  their  own  symptoms.  That  such  cases  are  exceptional 
does  not  lessen  their  importance. 

And  the  child  itself.  It  may  die  in  utero  and  be  expelled 
as  a  fetid  disorganized  mass.  It  may  be  born  to  live  but  a 
few  days.  It  may  reach  maturity,  bearing  in  mind  and  body 
the  scars  of  its  parent's  misfortune.  It  may  remain  well  many 
years  only  to  fall  victim  to  an  unsuspected  "  delayed  hereditary 
syphilis."  It  may  not  be  infected.  Freaks  of  fortune  and 
effects  of  treatment  ring  every  possible  change.  Of  twins  even, 
one  may  be  born  healthy,  the  other  syphilitic.  But,  generally 
speaking,  the  infection  lessens  with  each  succeeding  concep- 
tion. Thus,  when  a  man  in  the  infectious  stage  of  syphilis 
marries,  the  first  product  of  conception  usually  dies  in  ntero, 
and  miscarriage  of  a  deformed,  macerated  fetus  ensues.  After 
one  or  more  such  mishaps  a  child  is  born,  cachectic,  perhaps 
actively  syphilitic  at  birth  or  soon  showing  evidences  of  the 
disease.  Such  children  usually  die  promptly.  Later  children 
are  born  which  show  no  signs  of  the  disease  at  first,  and  may 
either  remain  well  or  show  certain  stigmata  of  syphilitic 
heredity,  or  become  actively  syphilitic. 

Hereditary  syphilis  is  the  same  disease  as  acquired  syphilis. 
But  its  lesions  are  modified  by  the  undeveloped  condition  of 
the  organism  attacked  as  well  as  by  the  mode  of  infection. 
Whether  the  fetus  is  infected  by  father  or  by  mother  (the 
theories  upon  this  subject  will  be  discussed  later),  there 
cannot  be  said  to  be  any  port  of  entry  for  the  virus  (unless 
it  be  the  placenta)  ;  hence  there  is  no  chancre,  no  primary 
lesion. 

The  secondary  infectious  lesions  are  sometimes  skipped  (or 
overlooked)  in  hereditary  syphilis,  and  the  so-called  delayed 
hereditary  syphilis  is  always  tertiary  in  type. 

But  the  overshadowing  features  of  hereditary  syphilis  are 
the  virulence  with  which   it  overwhelms  the  infant   and  the 


l8        THE    GENERAL    CHARACTERISTICS   OP   SYPHILIS 

characteristic  developmental  deformities  it  imparts,  deformities 
especially  of  the  teeth,  the  cranium,  and  the  remainder  of  the 
skeleton. 

CLINICAL  TYPES   OF  THE   DISEASE 

So  varied  is  the  course  of  syphilis,  so  distinctive  each  indi- 
vidual case,  that  it  is  a  thankless  task  to  attempt  any  classifica- 
tion which  will  absolutely  include  all  cases.  But,  if  for  no 
other  reason  than  to  show  the  futility  of  cut-and-dried  prog- 
noses, the  following  classification  may  be  of  service  : 

1.  Mild  early  syphilis. 

2.  Malignant  early  syphilis. 

3.  Mild  but  persistent  syphilis. 

4.  Relapsing  syphilis. 

5.  Malignant  late  syphilis. 

6.  Mild  late  syphilis. 

I.  Mild  Early  Syphilis. — Young  men  in  good  health  and 
with  good  habits  usually  suffer  very  little  from  syphilis  if  they 
attend  closely  to  hygiene  and  treatment.  A  type  case  has 
chancre  followed  by  one  or  two  early  skin  eruptions,  but  with- 
out any  marked  general  toxemia,  and  then  nothing  more,  un- 
less it  be  some  tendency  to  relapsing,  superficial  ulcers  of  the 
mouth  and  throat  for  a  year  or  two.  The  disease  may  end 
there ;  yet  every  experienced  syphilologist  has  learned  to  dread 
such  cases,  for  the  good  health  of  the  patient  during  the  active 
period  of  his  disease  and  the  absence  of  grave  or  disfiguring 
symptoms  leads  him  to  the  conclusion  that  his  syphilis  does 
not  amount  to  much  and,  in  spite  of  all  the  physician  can  do  to 
keep  him  to  his  duty,  he  is  very  likely  to  lapse  from  treatment, 
with  the  result  that,  whereas  he  might  have  cured  his  syphilis 
in  the  early  stages  had  he  been  more  attentive  to  its  manage- 
ment, he  neglects  himself  at  this  time  and  permits  the  disease 
to  acquire  that  hold  upon  him  which  will  later  show  itself  as 
relapsing  syphilis,  or  as  malignant  late  syphilis. 


CLINICAL    TYPES    OF    THE    DISEASE 


19 


Manifestly,  therefore,  the  mildness  of  early  syphilis  is  not 
an  unmixed  blessing. 

2.  Malignant  Early  Syphilis. —In  contrast  to  these  cases 
that  go  through  the  first  two  or  three  years  of  their  disease 
without  any  real  inconvenience,  are  those  tragic  ones  in  which 
the  patient  seems  to  be  overwhelmed  from  the  first  by  the  poi- 
son of  the  disease.  Within  the  past  year  I  have  seen  six  such 
cases,  which  are  sufficiently  typical. 

Case  III. — The  first  was  a  woman.  Her  outward  symptoms 
were  mrld,  nothing  more  than  a  light,  papular  syphilid ;  but  she 
developed  fever  and  lost  weight  progressively.  These  symptoms 
could  not  be  controlled  by  her  physician,  and  it  was  only  after 
six  months  of  fever  and  two  months  in  bed  that  vigorous  treat- 
ment finally  succeeded  in  controlling  the  disease,  which  has 
caused  no  symptoms  since.  But  in  the  meanwhile  she  had  devel- 
oped intestinal  tuberculosis,  and  when  I  saw  her,  six  years  later, 
she  had  also  a  tubercular  elbow  and  was,  physically  speaking, 
a  shadow  of  her  former  self.^  This  type  of  malignant  toxemia 
with  few  local  symptoms  is  more  common  among  women  than 
among  men. 

Case  IV. — Another  case,  a  young  man  in  robust  general 
health,  but  a  confirmed  drinker,  developed,  within  three  months 
of  the  beginning  of  his  disease,  multiple  ulcers  of  the  skin,  espe- 
cially of  his  face,  which  made  of  him  a  horrible  spectacle,  re- 
quired three  months  of  the  most  vigorous  treatment  to  cure,  and 
left  him  scarred  forever.  Doubtless  his  addiction  to  alcohol 
occasioned  the  violence  of  the  attack. 

Case  V. — In  a  third  case  the  patient  was  fifty-five  years  old 
and  developed,  within  three  months,  and  while  under  regular 
treatment,  first  a  double  iritis,  and  immediately  afterwards  a 
. "  gumma  "  of  the  iris  with  iridochoroiditis,  which  threatened  at 
one  time  to  cost  him  his  eye,  and  which  was  only  controlled  by 
treatment  so  vigorous  as  to  salivate  him  for  three  or  four  weeks. 
Immediately  thereafter  he  developed  diarrhea,  and  is  now  dying 
of  rectal  carcinoma. 

^  During  all  this  time  she  was  under  vigorous   antisyphilitic  treatment; 
she  came  to  me  vainly  trying  to  cure  her  elbow  by  passive  motion  and  calomel! 
4 


20        THE    GENERAL   CHARACTERISTICS    OF   SYPHILIS 

Case  VI. — The  fourth  case  is  the  most  striking  in  that  it 
occurred  in  a  young  and  healthy  woman  (infected  by  her  hus- 
band), in  whom  no  predisposing  cause  could  be  alleged  and 
whose  general  health  before  the  attack  seemed  perfect;  but  who 
was  rather  lightly  treated  at  first  because  her  symptoms  were 
insignificant,  until,  at  the  end  of  about  one  year,  she  developed 
an  ulcer  on  her  right  tonsil,  then  an  ulcer  on  the  left  one,  then 
rapid  gangrene  of  the  whole  soft  palate  and  of  much  of  the 
lateral  pharyngeal  walls,  then  gumma  of  the  base  of  the  tongue 
and  necrosis  of  the  lower  jaw.  To  control  this  outbreak  mer- 
cury had  to  be  administered  to  the  point  of  salivation,  iodides 
to  the  limit  of  toleration.  She  was  delirious  for  days  (from 
iodism),  unable  to  eat  solid  food  for  weeks.  The  attack  lasted 
six  months. 

Case  VII. — In  the  fifth  case  the  termination  was  not  happy. 
The  patient  had  mild  syphilis  for  six  months ;  then  his  wife 
noticed  that  he  dragged  his  left  leg.  Two  days  later  he  was 
suddenly  paralyzed  on  the  left  side.  Taken  to  a  hospital  and 
vigorously  dosed  for  two  months,  he  regained  partial  control  of 
his  muscles,  but  had  sunk  to  imbecility.  A  month  later  I  saw 
him,  feeble,  inarticulate,  drooling,  and  paralyzed,  with  a  rapid, 
feeble  pulse,  and  a  slight  temperature.  Ten  days  of  mixed  treat- 
ment left  him  worse  than  before,  and  a  few  days  later  he  died 
with  hyperpyrexia,  apparently  due  to  encephalitis. 

The  sixth  case  is  cited  elsewhere  (Case  XXVII,  page  231). 

3.  Mild  but  Persistent  Syphilis. — This  class  includes  the 
greatest  number  of  cases.  The  patients  do  fairly  but  not  abso- 
lutely well  under  treatment.  They  recover  from  one  set  of 
lesions  to  remain  well  only  a  few  months,  and  then  plunge  into 
another.  Often  the  cause  of  the  persistence  of  the  disease  is 
quite  manifest.  It  may  be  alcohol,  malaria,  tuberculosis,  bad 
hygiene,  or  inability  to  take  a  sufficient  amount  of  mercury 
or  iodides.  Such  cases  may  potter  along  year  after  year,  more 
or  less  sick,  to  their  own  despair  and  to  the  disgust  of  the 
physician  who  treats  them.  But  patient  care  and  the  applica- 
tion of  every  device  of  treatment — although  it  may  not  be  fol- 
lowed by  brilliant  results  at  the  time — will  slowly  wear  down 


CLINICAL   TYPES   OF   THE    DISEASE  21 

the  patient's  disease,  and  in  the  end  he  is  Hkely  to  be  perma- 
nently cured,  perhaps  more  Hkely  than  the  brilliant  case  of 
■mild  early  syphilis. 

4.  Relapsing  Syphilis. — All_sy:philis  is  relapsing  syphilis. 
It  breaks  out  when  or  where  it  will,  and  no  man  shall  say 
when  it  is  finished.  One  may  cruelly  but  truthfully  say  to  the 
patient  who  asks  for  an  absolutely  accurate  prognosis  of  his 
disease,  "  I  will  tell  you  whether  your  syphilis  is  grave  or  not 
after  you  are  dead."  Prognosis,  in  a  certain  sense,  we  can 
assuredly  give ;  but  swear  and  sign  and  seal,  we  never  can. 

5.  Malignant  Late  Syphilis. — The  patient  who,  after  years 
of  perfect  health,  develops  locomotor  ataxia  or  is  stricken  down 
by  an  apoplexy  or  develops  a  bone  gimima  is  a  type  of  malig- 
nant late  syphilis.  The  caption  is  employed  here  only  to  drive 
home  the  truth  that  such  accidents  may  happen  at  any  stage 
of  the  disease  (cf.  Cases  XVIII,  XIX,  and  XXI,  pages  98, 

lOl). 

6.  Mild  Late  Syphilis. — As  a  rule,  however,  if  syphilis  re- 
lapses after  many  years'  interval,  it  is  in  some  relatively  mild 
form :  a  tuberculo-squamous  patch,  a  chancre  redux,  a  tibial 
node,  or  a  tongue  ulcer.  Prompt  treatment  dissipates  the 
lesion  and,  if  treatment  is  kept  up  thereafter  for  a  year  or  so, 
another  relapse  need  not  be  expected.  Yet,  if  treatment  is 
neglected,  any  relapse,  however  mild  at  first,  tends  to  progress 
and  to  invade  other  organs  of  the  body  until  it  becomes  grave 
indeed. 


CHAPTER    III 

ETIOLOGY  OF  SYPHILIS 

Syphilis  has  long  been  classed  among  infectious  diseases, 
and  its  manifest  contagious  characteristics  have  made  it  seem 
certainly  parasitic  in  nature.  Some  twenty  or  thirty  alleged 
bacterial  causes  of  the  disease  have  been  described,  among 
which,  up  to  the  year  1905,  the  most  important  claimant  was 
the  bacillus  of  Lustgarten,  a  microbe  closely  resembling,  if  not 
identical  with,  the  smegma  bacillus.  But  in  May,  1905,  Schau- 
dinn  and  Hoffmann,  while  endeavoring  to  identify  the  Cytor- 
rhyctes  luis  (SiegeP),  one  of  the  alleged  causes  of  syphilis, 
observed  a  hitherto  undescribed  organism  in  the  secretions  from 
syphilitic  sores.  The  publication  of  their  findings  was  imme- 
diately followed  by  confirmatory  evidence  from  all  parts  of  the 
world.  Metchnikoff  and  Roux  not  only  confirmed  the  obser- 
vation, but  called  attention  to  the  fact  that  Bordet  and  Gengon 
had  previously  observed  this  microorganism  in  certain  syphi- 
litic secretions,  but  not'  finding  it  constantly  had  dropped  fur- 
ther investigation.  Levaditi  found  it  in  lesions  of  congenital 
syphilis.  Bertarelli,  Volpino,  and  Bovero  were  able  to  iden- 
tify it  in  stained  sections  of  syphilitic  organs.  Larrier  and 
Bergeron  have  recently  identified  it  in  the  blood  of  syphilitic 
patients,  and  innumerable  observers  in  every  country  have 
noted  clinically  that  the  organism  may  be  found  in  almost 
every  lesion  of  early  untreated  syphilis,  though  most  common 
in  the  most  infectious  lesions. 

» Munch,  med.  Wochenschr.,  1906,  vol.  liii.,  p.  2. 


THE   SPIROCHETA   PALLIDA  23 

So  overwhelming  indeed  is  the  mass  of  evidence  that,  in 
spite  of  the  fact  that  the  organism  has  not  been  cultivated, 
it  seems  certain  that  the  cause  of  syphilis  has  at  last  been  found, 
and  we  may  safely  say  that  the  spirocheta  of  Schaudinn  is 
either  the  cause  of  syphilis  or  one  phase  in  the  life  cycle  of 
some  microorganism  which  is  the  cause  of  syphilis. 


THE   SPIROCHETA   PALLIDA 

The  Spirocheta  pallida  (spironema,  treponcma'^  pallida) 
best  shows  its  characteristics  when  examined  alive  in  the  secre- 
tion of  an  infectious  syphilitic  lesion.  It  may  be  examined  in 
a  hanging  drop  or,  better,  mounted  under  a  cover  glass  and 
sealed  with  wax  or  paraffin. 

It  is  a  spiral  organism  (PI.  I),  varying  in  length  from 
4  to  14  IX,  in  diameter  from  an  immeasurable  thinness  up  to 
about  l/i.;  it  is  cylindrical,  not  flattened;  its  spirals  usually 
number  from  6  to  14,  though  as  high  as  20  and  25  have  been 
counted  in  exceptionally  long  ones.  The  length  and  depth  of 
the  spirals  varies  from  i  to  1.5  /*. 

It  is  a  motile  organism,  having  three  modes  of  motion; 
viz.,  a  corkscrew  rotation  on  its  own  axis,  a  gliding  back  and 

'  The  name  "treponema"  was  suggested  by  Schaudinn  as  more  accurately 
descriptive  of  the  exact  nature  of  the  parasite.  But  this  name  has  met  with  no 
general  favor  and  the  special  features  upon  which  Schaudinn  based  his  preference 
are  still  contested.  Indeed,  so  Httle  is  yet  known  about  the  spirochete,  that 
it  is  impossible  to  place  them  as  a  class,  still  less  to  determine  accurately  the 
relative  positions  of  individual  members  of  that  class. 

Whether  S.  pallida  is  a  bacterium  or  a  protozoon,  whether  it  divides  by 
longitudinal  or  by  transverse  fissure,  whether  its  flagella  are  real,  whether  it  has 
an  undulating  membrane  and  nuclei,  the  future  mu^  decide. 

The  most  recent  contributions  summing  up  our  present  knowledge  of  S. 
pallida  are:  Sobemheim,  i/anft.  d.  Path.  Microorg.,  1907,  No.  2,  p.  527  (with 
eleven  pages  of  bibliography)  and  in  American  literature,  Rosenberger,  Am. 
J.  Med.  Sci.,  1906,  vol.  cx.xxi,  p.  143;  Pfender,  Am.  Med.,  1906,  vol.  xi,  p.  350; 
and  Ewing,  N.  Y.  State  J.  0}  Med.,  1907,  vol.  vii,  p.  177. 


24  .    ETIOLOGY    OF    SYPHILIS 

forth,  and  a  bending  upon  its  axis.  In  fresh  specimens  these 
motions  are  very  active,  but  do  not  appear  to  entail  any  mate- 
rial progress  from  one  spot  to  another,  for  a  specimen  remains 
for  hours  in  the  microscopic  field. 

It  is  a  peculiarity  of  6^.  pallida  that,  whether  in  motion  or 
at  rest,  it  retains  its  spiral  shape. 

Although  fixing  and  staining,  of  course,  destroy  its  activ- 
ity and  somewhat  distort  its  spirals,  so  tenuous  an  organism 
cannot  be  accurately  studied  unless  stained.  Under  these  con- 
ditions it  shows  a  tapering  at  each  extremity,  which  is  some- 
times adorned  with  one  or  two  flagella  and  a  tendency  to  occur 
in  irregidar,  overlapping,  or  star-shaped  groups.  The  spi- 
rochetse  often  lie  adjacent  to  or  overlap  red  blood  corpuscles. 
They  are  practically  always  extracellular. 

Methods  of  Staining. — The  Spirochcta  pallida  approxi- 
mates the  protozoa  in  its  resistance  to  the  usual  bacterial  stains. 
The  classic  method  of  preparing  and  staining  is  Schaudinn  and 
Hoffmann's  modification  of  Giemsa,  as  follows : 

1.  Obtain  the  specimen  by  scratching  the  surface  of  the 
lesion  (chancre,  mucous  patch),  after  having  washed  it  thor- 
oughly clean  of  all  contamination  ^ — the  admixture  of  a  trace 
of  blood  does  no  harm.  Spread  the  secretion  thus  obtained  as 
thin  as  possible;  dry  zinthout  heating;  harden  for  fifteen  min- 
utes in  absolute  alcohol. 

2.  Employing  the  Giemsa  stain  (made  by  Griibler,  of 
Leipzig),  dilute  this  by  adding  about  one  drop  to  i  c.c.  of 
water  (to  which  one  to  ten  drops  of  i  :  i,ooo  calcium  car- 
bonate has  been  previously  added — this  is  advantageous  but 
not  essential). 

1  Rille  and  Vockerodt  found  that  antiseptic  wet  dressings  eliminate  mixed 
infection  without  affecting  the  spirochetie.  Inasmuch  as  the  spirochetae  lie 
among  the  epithelia  rather  than  upon  them,  the  best  results  are  obtained  by 
scraping  the  lesion  quite  deeply.  The  fewer  leucocytes  in  the  exudate  the 
more  spirochetae  it  is  likely  to  contain  (Ewing). 


^ 

^ 

,,— V 

7t 

■ 

^ 

3 

„ 

■A 

K 

^ 

.E 

j: 

u 

tn 

CA 

Ph 

H 

-4-* 

c 

THE    SPIROCHETA    PALLIDA  25 

3.  Immediately  spread  the  diluted  stain  on  the  specimen 
and  let  it  stand  one  hour. 

4.  Wash  freely  in  water,  dry  without  heating,  and  mount. 
This  is  the  standard  stain.     A  quicker  method  is  that  of 

Simonelli  and  Bandi  ^  or  of  Goldhorn,-  sold  in  this  country 
under  the  name  of  Goldhorn's  stain.  A  few  drops  of 
this  will  stain  a  specimen  (dried  without  heating)  in  two 
or  three  seconds.  The  smear  is  then  rinsed  in  water  and 
dried  (cold). 

In  France  a  favorite  stain  is  the  Marino  blue ;  innumerable 
other  stains  have  been  tried,  but  the  Giemsa  and  the  Goldhorn 
fill  all  requirements.  With  Giemsa  the  spirochetse  appear  of  a 
faint  red  color.  The  Goldhorn  stains  them  purplish,  which 
may  be  changed  to  brownish  black  by  treating  the  specimen 
with  gram  or  lugol. 

Tissue  Stain. — The  best  is  Levaditi's  modification  of  the 
Ramon  y  Cajal  silver  stain. ^  , 

1.  Sections  are  cut  i  mm.  thick  and  hardened  in  ten  per 
cent  formalin  for  twenty-four  hours. 

2.  Wash  and  harden  in  ninety-six  per  cent  alcohol  twenty- 
four  hours. 

3.  Wash  a  few  minutes  in  water  until  they  sink. 

4.  Impregnate  with  silver  by  soaking  for  three  (to  five) 
days  in  a  1.5  per  cent  (to  three  per  cent)  solution  of  silver 
nitrate  at  a  temperature  of  38°  C. 

5.  Wash  rapidly  in  water  and  place  for  twenty-four  (to 
forty-eight)  hours  at  the  room  temperature  in 

Acid  pyrogallic 2  gm. ; 

Formalin 5  c.c. ; 

Aq.   destill 100  c.c. 

'  Ccntralbl.  j.  Bad.,  Parasit.  v.  Inject.,  1905,  vol.  xl,  p.  159. 
^/.  oj  Expcr.  Med.,  1906,  vol.  viii,  p.  451. 

'  The  so-called  old  Lcvaditi,  in  contradistinction  to  the  new  or  pyridin 
Levaditi,  which  is  quicker  but  not  so  accurate. 


26  ETIOLOGY   OF   SYPHILIS 

6.  Wash,  dehydrate  in  absolute  alcohol,  and  mount  in 
paraffin. 

7.  Cut  sections  no  thicker  than  5  /*. 

8.  Stain  either  with  (a)  Giemsa,  for  a  few  minutes;  wash 
in  water,  differentiate  in  alcohol  containing  a  few  drops  of  oil 
of  cloves,  clarify  in  xylol,  and  mount  in  balsam;  or  (b)  con- 
centrated toluidin-blue  solution,  differentiate  in  alcohol  con- 
taining a  few  drops  of  Unna's  ether-glycerin  mixture — xylol, 
balsam. 

Diagnosis  of  S.  Pallida. ^ — The  time  and  skill  required  to 
perform  the  Levaditi  stain  successfully  suffice  to  keep  tissue 
staining  apart,  to  be  employed  only  by  the  most  competent 
specialists.  Current  examinations  for  Spirocheta  pallida  may 
be  attempted  only  on  smears  stained  with  Goldhorn  or  Giemsa. 

Examination  of  such  a  smear  promptly  reveals  how  appro- 
priate is  the  name,  5.  pallida;  for  so  pale  and  thin  are  these 
microorganisms,  that  at  first  one  finds  great  difficulty  in  per- 
ceiving them.  It  has  been  generally  noted  that  the  observer  at 
first  makes  very  few  positive  finds.  But,  having  at  last  iden- 
tified the  spirocheta  and  got  it  photographed,  as  it  were,  on  his 
retina,  he  can  return  to  specimens  previously  found  negative 
and  discover  the  organism  in  them — perhaps  in  great  numbers. 

Hence  the  discovery  of  .9.  pallida  requires  not  only  famil- 
iarity with  ordinary  laboratory  and  microscopic  technic,  but 
also  a  relatively  long  and  tedious  special  training.  Unhap- 
pily, it  is  to  be  foreseen  that,  as  spirocheta  diagnosis  assumes 
greater  and  greater  prominence  in  the  diagnosis  of  syphilis, 
the  tribe  of  near  pathologists  will  feel  fully  competent  to  pass 
upon  this — the  most  delicate  point  in  the  diagnosis  of  the  most 
important  infectious  disease  that  afflicts  mankind ;  to  the  cock- 
sure diagnosis  of  the  hasty  practitioner  will  be  added  the 
scientific   diagnosis   of   incompetence.      For   spiral   organisms 


'  The  diagnosis  by  inoculation  is  referred  to  on  page  31. 


THE   SPIROCHETA   PALLIDA  27 

abound  both  upon  the  skin  and  upon  the  mucous  membranes. 
In  the  mouth  are  found  S.  denticula,  S.  buccalis,  S.  Vincenti; 
in  the  bowel,  6^.  dyscntcria;;  on  the  skin,  5.  refriiigens  and 
various  saprophytic  varieties. 

The  accompanying  photographs  (PI.  I)  show,  however, 
the  characteristic  features  distinguishing  5".  pallida  from  ever}'' 
other  variety  of  spirocheta.     These  are : 

1.  Extreme  tenuity  and  faint  staining. 

2.  Multiple  small,  abrupt  spirals. 

All  of  the  other  familiar  spirochetae  are  much  thicker  (most 
of  them  are  longer),  stain  readily  with  the  common  dyes,  and 
exhibit  long,  gentle  undulations  in  brilliant  contrast  to  the 
sharp,  short,  almost  angular  spirals  of  5.  pallida. 

This  is  not  to  say  that  every  vS".  pallida  seen  can  be  identi- 
fied as  such,  or  that  every  specimen  containing  S.  pallida  can 
be  diagnosed  even  by  the  most  skilled  observer.  Indeed,  quite 
the  converse  is  true.  Even  Neisser  confesses  to  a  doubt  about 
certain  of  his  cases.  But  a  characteristic  5^.  pallida  is  as  typical 
to  a  skilled  eye  as  is  a  characteristic  gonococcus,  for  example, 
and  affords  quite  the  same  diagnostic  certainty. 

But  before  a  negative  report  can  be  given,  repeated,  pro- 
longed, systematic,  and  skilled  examinations  must  be  made. 

Where  may  S.  Pallida  be  Found? — The  earlier  observers 
were  able  to  discover  5".  pallida  only  in  the  earliest  (and  most 
infectious)  lesions  of  the  disease.  The  following  condensed 
list  shows  the  results  obtained  by  those  reporting  the  greatest 
number  of  cases. 

Oppenheim  and  Sachs  examined  118  cases,  with  39  posi- 
tive results. 

Mulzer,  22  cases,  2  positive;  56  controls,  all  negative. 

Nicolas,  Eavre,  and  Andre,  42  cases;   13  positive. 

Kraus  and  Prautschoff,  37  chancres ;  32  positive,  25  sec- 
ondaries, 18  positive. 

Siebert,  18  chancres;  13  positive,  46  secondaries,  39  posi- 


28  ETIOLOGY   OF   SYPHILIS 

tive;  46  control  examinations  negative;  6  lymph  node  serum 
negative;  7  gummata  negative;  cerebro-spinal  fluid,  blood  and 
semen  negative. 

Sobernheim  and  Tomasczewski,  50  cases,  all  positive;  28 
controls,  all  negative. 

Scholtz,  37  cases,  all  positive. 

Schaudinn  (second  report),  70  cases,  all  positive. 

Roscher,  32  chancres,  31  positive;  58  moist  papules,  55 
positive;  40  dry  papules  and  pustules,  34  positive;  29  mouth 
lesions,  28  positive ;  38  lymph  node  serum,  30  positive ;  24  con- 
trols negative. 

Sufficiently  expert  and  conscientious  investigation,  there- 
fore, reveals  vS.  pallida  in  fully  three  fourths  of  the  smears 
taken  from  chancres,  moist  papules,  and  mouth  lesions. 

It  was  to  be  hoped  that  aspiration  of  the  lymph  nodes 
adjacent  to  the  chancre  might  prove  a  simple  means  of  obtain- 
ing uncontaminated  smears  of  S.  pallida;  but,  unfortunately, 
the  microorganism  is  rare  in  the  center  of  nodes,  being  chiefly 
confined  to  the  region  of  the  periphery,  so  that  there  is  a  dis- 
tinctly less  probability  of  finding  them  there  than  in  the  chan- 
cre itself. 

Though  the  later  secondary  lesions  contain  fewer  spiro- 
chetae,  these  have  been  found  as  late  as  nine  years  after  chancre 
by  Sobernheim  and  Tomasczewski. 

They  have  been  found  in  the  pus  from  a  non-syphilitic 
abscess  occurring  during  the  acute  stage  of  the  disease 
(Fliigel),  in  the  serum  of  blisters  raised  by  cantharides 
(Levaditi  and  Petresco),  in  albuminous  urine  (Dreyer  and 
Toepel),  in  the  blood — after  many  failures,  and  only  during 
the  first  few  months  and  before  the  beginning  of  mercurial 
treatment  (Noggerath  and  Stahelin,  Schaudinn,  Richards  and 
Hunt  et  al.). 

Most  interesting  of  all  has  been  the  search  for  spirochetae 
in  tertiary  lesions,  which,  for  a  long  time,  was  fruitless,  but 


PLATE    II. 


Fig.  I. 


Fig. 


PLATE   II. — Spirochet.e  in  Tissues. 

Fig.  I. — Macular  syphilid.  Section  of  venous  capillary,  showing  distribution 
of  spirochetc'e  and  phagocytosis  by  leukocytes  and  fibroblasts  (at  F,  L,  P).  (Ehr- 
mann.) 

Fig.  2. — Spirochete  in  bone  marrow  in  hereditary  syphilitic  osteo-chondritis. 
(Bertarelli.) 


THE    SPIROCHETA    PALLIDA  29 

was  finally  crowned  with  success  (page  T^y).  Tomasczewski, 
who  has  found  them  in  five  out  of  ten  gummata  examined, 
states  that  eight  to  ten  hours  must  sometimes  be  spent  in  ex- 
amining smears  before  finding  a  typical  spirocheta. 

The  moist  lesions  of  early  hereditary  syphilis  swarm  with 
spirochetse,  and  they  have  been  found  (either  in  smears  or  in 
sections)  in  practically  all  the  organs  of  stillborn  syphilitic 
infants;  viz.,  liver,  lung,  spleen,  kidney,  suprarenal  muscle, 
heart,  stomach,  intestine,  mesenteric  glands,  gall-bladder  and 
ducts,  ovary,  uterus,  prostate,  testis,  urinary  bladder,  thymus, 
tonsil,  bone,  joint,  etc.  They  are  usually  most  numerous  in 
the  liver,  lungs,  and  skin.  They  have  been  found  in  both  fetal 
and  maternal  placenta,  and  once  in  the  inguinal  glands  of  the 
apparently  healthy  mother  of  a  syphilitic  child  (Buschke  and 
Fischer)  !  Curiously  enough  masses  of  spirochetae  are  some- 
times found  in  and  about  the  capillaries  where  no  tissue  change 
has  taken  place. 

They  have  not  been  found  in  the  cerebro-spinal  fluid, 
though  they  doubtless  will  be,  for  positive  inoculations  have 
been  obtained  upon  monkeys  with  this  fluid  (Hoffmann). 

The  examination  of  normal  secretions — except  the  semen — • 
is  always  negative,  except  in  severe  congenital  syphilis  (page 
53).  Whether  the  exception  in  the  case  of  semen  is  due  to 
syphilitic  lesions  in  the  seminal  canals  it  is  impossible  as  yet 
to  say. 

Distribution  and  Fate. — Though  spirochetae  have  been 
kept  alive  for  a  few  days  on  artificial  media,  none  of  the  at- 
tempts at  artificial  cultivation  have  thus  far  been  successful.^ 
Hence  we  are  not  in  a  position  to  aflirm  with  absolute  cer- 
tainty that  the  spirocheta  is  self-suflicient,  self-multiplying,  like 
the  known  bacteria,  and  not  a  mere  developmental  form  of 
some  unknown  organism   (possibly  the  cytorrhictes).     More- 

>  Quite  recently  5.  refringens  has  been  cultivated  by  Levaditi;  S.  obermeieri 
by  Novy;  perhaps  S.  pallida  will  be  the  next. 


3° 


ETIOLOGY    OF    SYPHILIS 


over,  the  multiplication,  distribution,  and  fate  of  the  spirocheta 
in  the  body  of  a  syphilitic  patient  have  not  been  worked  out  in 
detail.     But  the  following  facts  we  know : 

Spirochetas  are  found  most  frequently  in  the  earliest  and 
most  infectious  lesions  of  syphilis.  Whether  in  the  chancre 
and  early  secondary  lesions  of  acquired  syphilis  or  in  the  organs 
in  inherited  syphilis,  they  abound  in  the  walls  of  the  blood- 
vessels and  in  the  perivascular  tissues.  They  are  relatively 
rare  in  the  lymph  vessels,  surprisingly  few  in  the  nodes,  and 
when  found  in  the  nodes  are  usually  in  or  about  the  blood  capil- 
laries at  their  circumference  (Hoffmann  and  Beer).  They 
have  been  found  in  great  numbers  among  the  epithelia  of  the 
chancre  or  the  moist  papule.  A  few  observers  believe  they 
have  seen  evidence  that  the  spirochetse  are  destroyed  by  phago- 
cytosis. In  tertiary  lesions  (gummata)  they  have  been  found 
only  in  the  active,  advancing  edge  of  the  lesion,  never  in  its 
necrotic  center  or  in  its  secretion. 

It  seems  probable,  therefore,  that  the  spirochetse  are  dis- 
tributed by  the  lymph  rather  than  by  the  blood  current,  directly 
excite  the  perivascular  inflammation  characteristic  of  all 
syphilitic  lesions,  and  are  destroyed  by  phagocytosis. 

Although  a  few  observers  have  denied  that  the  administra- 
tion of  mercury  has  any  effect  upon  the  spirocheta,  it  is  the 
consensus  of  opinion  that,  as  soon  as  mercury  is  administered, 
the  spirochetse  rapidly  disappear  and  soon  are  undiscoverable, 
and  this  disappearance  seems  to  be  especially  rapid  under 
inunction  and  hypodermic  medication. 

EXPERIMENTAL   SYPHILIS 

The  countless  attempts  at  animal  inoculation  made  with  the 
virulent  secretions  of  syphilitic  lesions  before  Schaudinn's  dis- 
covery of  the  spirocheta  may  all  be  accounted  failures,  with  the 
exception  of  the  chimpanzee  successfully  and  convincingly  in- 


< 


s       CI, 
^3      S 


EXPERIMENTAL    SYPHILIS  31 

oculated  with  syphilis  by  Metschnikoff  and  Roux  in  1903.  But 
even  this  experiment  derives  much  of  its  force  from  the  con- 
firmation of  post-spirocheta  investigations.  Of  all  the  rest, 
w^hether  upon  monkeys,  dogs,  cats,  or  other  animals,  the  best 
that  can  be  said  is  that  they  were  doubtful  and  unconvincing. 

But  with  the  advent  of  the  spirocheta  it  became  possible 
to  follow  the  infecting  agent  as  well  as  the  infective  lesion; 
to  find  spirochetse  in  the  infectious  secretion,  again  in  the  re- 
sulting sore,  and  again  in  other  chancres  produced  by  inocula- 
tions made  from  this  sore  upon  other  animals. 

Much  work  has  been  done  in  this  line  by  the  distinguished 
chiefs  of  the  Institut  Pasteur  at  Paris,  by  Neisser,  who  made  a 
special  trip  to  the  tropics  for  this  purpose,  and  by  others. 
These  investigators  have  proven  beyond  possible  doubt  that 
monkeys  may  be  infected  with  syphilis,  and  have  even  worked 
out  the  type  of  simian  syphilis. 

The  anthropoids  develop  chancre  followed  by  secondary 
skin  lesions  closely  resembling  those  found  in  man.  Moreover, 
they  sometimes  become  markedly  cachectic,  and  may  even  be 
paralyzed;  but  this  acute  stage  is  of  very  brief  duration,  and 
is  not  followed,  as  far  as  known,  by  any  evidence  of  tertiar- 
ism.  In  the  lower  orders  of  monkeys  inoculation  can  be  per- 
formed only  upon  certain  parts  of  the  body  (eyebrows,  eyelids, 
genitals)  and  is  followed,  after  the  chancre,  by  but  few  and 
irregular  evidences  of  general  infection  (skin  lesions,  tox- 
emia). 

In  other  animals  successful  inoculations  have  been  made; 
but  the  resultant  syphilis  is  a  travesty  on  the  dire  disease  we 
know.  Thus  Bertarelli,  Hoffmann,  and  Scherber  have  inocu- 
lated the  corneas  of  bitches  and  produced  a  localized  typical 
syphilitic  inflammation  from  which  spirochetse  could  be  ob- 
tained.    But  such  investigations  are  of  no  practical  import. 

But  from  the  results  of  monkey  inoculation  many  and  most 
important  inferences  have  been  drawn.     It  were  impracticable 


32  ETIOLOGY   OF   SYPHILIS 

to  relate  them  here  in  full  detail.  The  student  will  find  prac- 
tically all  of  them  in  the  writings  of  Metschnikoff  and  Roux/ 
and  in  the  report  of  Neisser,  Boermann,  and  Halberstadter.^ 
We  must  summarize  as  follows : 

Inoculation.— It  is  impossible  to  inoculate  by  subcutaneous 
injection.  The  secretions  clinically  the  most  infectious  are  ex- 
perimentally the  most  noxious;  yet  it  is  possible  to  perform 
successful  inoculations  and  to  obtain  characteristic  spirochetse 
from  the  resultant  lesions,  although  the  most  careful  examina- 
tion of  the  inoculating  fluid  fails  to  reveal  in  it  any  spirochetae. 
Successful  inoculations  have  been  made  with  human  blood 
(Hoffmann,  Finger)  and  with  fragments  of  gummata  (Fin- 
ger, Nitze),  but  only  after  repeated  failures.  Finger  obtained 
a  positive  inoculation  with  apparently  normal  seminal  fluid. 

Reinoculation  (producing  multiple  chancres)  is  possible 
for  from  ten  to  fourteen  days;  after  this — as  in  man  (page 
225) — it  is  impossible. 

But  the  most  important  practical  conclusion  yet  reached  is 
that  syphilitic  secretions  cease  to  he  infections  after  tzvelve  to 
twenty-four  hours,  and  much  sooner  (at  most  six  hours)  zvhen 
dry.  This  explains  why  we  are  not  all  infected  by  cigars  and 
why  the  syphilitic  may  live  and  dine  with  his  family  in  abso- 
lute safety  so  long  as  the  cups,  forks,  and  spoons  that  enter 
his  mouth  are  washed  and  dried  before  being  used  by  anyone 
else  at  the  following  meal. 

Prophylaxis.— As  soon  as  Metschnikoff  and  Roux  had 
proved  to  their  satisfaction  the  transmissibility  of  syphilis  to 
monkeys,  they  turned  their  attention  to  its  prophylaxis.  The 
results  of  their  experiments  were  startling.  They  found  that 
excision  of  chancre,  even  of  commencing  chancre,  is  entirely 
futile  as  a  preventive  or  minimizer  of  the  subsequent  develop- 

1  Bull,  de  rinstitut  Pasteur,  vol.  i,  p.  620;  vol.  ii,  pp.  113,  178;  vol.  iii,  pp. 
73,  451;  vol.  iv,  p.  116;  also  Annates  de  VInstitut  Pasteur. 

^Deutsche  med.  Wochenschr.,  1906,  vol.  xxxii,  pp.  i,  49  and  97. 


EXPERIMENTAL    SYPHILIS  33 

ment  of  the  disease.  Cauterization  of  the  chancre  they  found 
equally  futile.  Indeed,  wide  excision  of  the  inocidated  area  at 
any  time  later  than  eight  hours  after  inocidation  failed  to  pre- 
vent the  development  of  chancre'^  (confirmed  by  Neisser). 
Moreover,  the  application  of  heat  to  the  site  of  inoculation  (to 
destroy  the  virus)  and  of  various  antiseptics  (including  strong 
solutions  of  sublimate)  availed  nothing. 

The  only  way  in  which  they  were  able  to  destroy  the  virus 
after  inoculation  was  by  applying,  within  six  hours,  a  calomel 
salve  (calomel  20,  lanolin  40).  So  universally  preventive  did 
this  prove  that  they  performed  a  confirmatory  inoculation 
(with  monkey  controls)  upon  a  medical  student,  inoculating 
him  with  the  virulent  secretion  of  a  chancre  and  of  a  mucous 
papule,  rubbing  in  the  calomel  salve  within  one  hour,  and 
watching  him  long  enough  to  be  sure  that  no  sign  of  syphilis 
developed. 

Hence  we  may  infer  that  the  only  personal  prophylaxis 
against  syphilitic  infection  lies,  not  in  cauterization  or  exci- 
sion, but  in  inunction  with  a  strong  mercurial  ointment  within 
one  hour  ~  of  inoculation. 

Inoculation  Immunity. — All  efforts  to  develop  artificially 
either  an  active  or  a  passive  immunity  to  syphilis  have  failed 
in  man  as  well  as  in  monkey.  Taking  as  a  starting  point  the 
immunity  to  reinfection,  which  begins  so  early  in  the  disease 
(tenth  to  fourteenth  day),  and  usually  lasts  a  lifetime,  inocu- 
lation experiments  have  been  made  with  the  blood  serum  of 
syphilitics,  with  the  juices  from  syphilitic  lesions  (filtered 
through  porcelain),  as  well  as  by  "passing"  the  infection 
through  several  individuals.  The  result  has  been  absolute 
zero :  as  yet  "  the  only  way  to  be  immune  to  syphilis  is  to 
have  it." 


*  But  in  one  case  amputation  of  an  inoculated  ear  after  twenty-four  hours 
was  preventive,  and  the  monkey  was  subsequently  successfully  inoculated. 
^  Perhaps  as  late  as  six  hours  the  remedy  might  still  be  eflicacious. 


34 


ETIOLOGY    OF    SYPHILIS 


Serum  Diagnosis  and  Treatment. — In  this  line  lie  our 
brightest  hopes  for  practical  results  from  animal  inoculation. 
Imagine  what  would  become  of  syphilis  on  the  discovery  of 
a  diagnostic  chemico-physiologic  test  and  of  a  therapeutic 
serum!  The  promise  that  some  such  sera  may  soon  be  ob- 
tained is  almost  too  good  to  believe.  Thus  far  no  practical 
results  have  been  obtained/  though  Wassermann,  Neisser,  and 
Bruck  claim  to  have  shown  the  development  in  infected  mon- 
keys of  a  syphilitic  immune  substance. 

^  The  Wassermann  diagnostic  serum  has  given  accurate  findings  in  little 
over  half  the  cases  tested  (Cf.  Ewing). 


CHAPTER    IV 
THE  NATURE  OF  SYPHILIS 

At  this  date  when  the  protozoal  (or  microbic)  cause  of 
syphihs  has  just  been  discovered  and  a  study  of  its  nature  has 
scarcely  begim,  it  seems  futile  to  waste  many  words  over  an- 
cient theories  concerning  the  nature  of  the  disease;  for  scien- 
tific investigations  of  the  coming  decade  will  surely  modify  the 
more  or  less  accurate  guesswork  upon  which  we  have  hitherto 
depended. 

At  present  we  may  be  sure  that  syphilis  is  an  infectious 
disease.  As  such  its  primary  and  early  secondary  lesions  are 
readily  explicable.  These  local  lesions  are  inflammatory  in 
type,  a  reaction  to  aggregations  of  the  specific  protozoa.  Ac- 
cordingly their  secretion  is  infectious  and  contains  the  spircH 
cheta. 

But  tertiary  lesions  are  not  clinically  infectious,  contain 
relatively  few  spirochetse,  and  often  appear  after  an  interval 
of  years,  during  which  the  patient  has  apparently  enjoyed 
perfect  health.  How  shall  we  interpret  these  characteristics, 
how  explain  the  malignancy  of  these  lesions  as  contrasted  with 
the  mildness  of  those  early  ones  that  abound  in  spirochetse? 

Many  theories  have  been  conceived  to  explain  the  facts. 
We  lack  space  to  consider  them  in  detail.^  They  may  be 
classed  under  three  heads : 

*  Neumann  {Medical  Record,  1906,  vol.  Ixix,  p.  649)  has  recently  published 
a  masterly  summary  and  critique  on  this  subject.  Thalmann  (Miinch.  med. 
Wochenschr.,  1907,  vol.  liv,  p.  601)  reviews  the  subject  in  the  light  of  the  re- 
cently discovered  spirocheta  and  its  relation  to  the  body  cells  according  to 
Ehrlich's  theory. 

5  35 


36  THE   NATURE   OF   SYPHILIS 

1.  Unna  believes  that  the  late  lesions  of  syphilis  are  local 
recrudescences  in  the  site  of  old  lesions.  The  distribution  of 
the  poison  occurs  in  the  first  few  years  of  the  disease.  There- 
after local  areas  of  inflammation  may  remain  for  years 
dormant  and  unsuspected  until,  stimulated  by  local  trauma 
or  general  debility,  they  awake  to  a  purely  local  renewed 
activity.  ^ 

2.  Finger  maintained  that,  although  the  primary  and  sec- 
ondary lesions  are  due  to  the  microbic  (or  protozoal)  cause  of 
syphilis,  the  tertiary  lesions  are  toxic  in  character  and  due  to 
the  poisons  evolved  by  these  microbes.  (The  discovery  of 
spirochetse  in  gumma  and  its  proven  infectiousness  have  led 
Finger  to  give  up  this  theory.) 

3.  Most  authorities,  notably  Neumann  and  Lang,  accept  in 
a  modified  way  the  theory  of  Virchow.  The  microorganisms 
which  cause  the  primary  and  early  secondary  symptoms  are 
supposed  to  be  destroyed  only  in  part.  They  lie  dormant  in 
the  lymph  nodes  (Virchow)  or  in  other  regions  (Lang),  or 
in  the  scars  of  old  syphilitic  lesions  (Neumann)  until,  awak- 
ened by  trauma  or  debility  of  the  host  or  by  their  own  gradual 
multiplication,  they  suddenly  set  up,  not  a  local  reaction,  not  a 
general  toxemia,  but  a  general  septicemia,  as  it  were,  a  re- 
newed spreading  of  infection  throughout  the  system.  Hence 
result  the  various  late  secondary  or  tertiary  symptoms,  differ- 
ing in  distribution  and  in  quality  from  the  first  outbreak  of 
the  disease  because  the  host  is  partially  immunized. 

Experimental  syphilis  (in  animals)  is  rapidly  solving  many 
of  the  problems  suggested  by  these  conflicting  theories. 

The  Contagiousness  of  Gumma. — ^The  most  important 
questions  thus  far  solved  by  experimental  inoculation  relate  to 
the  theories  of  infection.  But  one  point  may  be  emphasized 
here :  the  contagiousness  of  gumma  has  been  definitely  proven. 
We  have  already  had  occasion  to  state  that  clinically  gumma  is 
not  contagious.     A  very  few  exceptions  to  this  clinical  rule 


THE    NATURE    OF   SYPHILIS  37 

have  been  recorded  (cf.  Williams  ^),  but  their  very  rarity- 
makes  them  suspect.  Indeed,  every  attempt  at  inoculation  of 
gummatous  secretions,  even  upon  non-immune  human  beings, 
failed  until  1905.  In  that  year  both  Finger  and  Neisser  suc- 
cessfully inoculated  monkeys  with  the  scrapings  from  an  active 
but  not  ulcerated  gumma.  Previous  experimenters  had  em- 
ployed the  secretions  of  ulcerated  lesions,  and  herein  lay  the 
secret  of  their  failure.  They  worked  with  a  virus  whose 
feeble  contagiousness  was  overcome  (doubtless  by  destruction 
of  the  spirocheta)  by  mixed  infection  with  the  vulgar  pyogenic 
cocci.  The  success  of  Finger  and  Neisser  was  due  to  the 
employment  of  an  uncontaminated  virus  obtained  by  curettage 
or  incision.  Herein,  too,  lies  the  distinction  between  thfe  clin- 
ical innocuousness  of  gumma  and  its  actual  contagiousness. 
Its  ordinary  secretions  are  not  contagious,  though  itself  con- 
tains a  virus  vivuin  and  is  contagious.  The  distinction  would 
seem  a  perilously  tenuous  one  to  put  faith  in  were  it  not  borne 
out  by  an  infinity  of  clinical  experience.  That  the  duration 
of  the  disease  has  no  effect  upon  the  contagiousness  of  the 
lesion  is  proven  by  the  fact  that  one  of  Neisser's  successful 
inoculations  was  made  from  a  gumma  occurring  in  the  tenth 
year  of  the  disease. 

Persistence  of  Spirocheta. — The  proven  infectiousness  of 
gumma  at  so  late  a  date,  the  evidence  (page  29)  that  all 
gummata  probably  (and  from  thirty  per  cent  to  fifty  per  cent 
of  them  certainly)  contain  spirochetse,  the  possibility  (page 
61)  that  syphilis  may  remain  infectious  long  after  the  ap- 
pointed five  years,  the  assurance  (page  65)  that  an  appar- 
ently sound  syphilitic  woman  may  continue  to  bear  syphilitic 
children  for  ten,  fifteen,  and  twenty  years,  and  the  belief  of 
certain  excellent  authorities  (page  75)  in  syphilis  of  the  third 
generation,   combine   in  cumulative  probability  to  show  that 

'  Med.  Record,  1906,  vol.  Ixix. 


38  THE    NATURE   OF    SYPHILIS 

the  persistence  of  spirochetse  ^  is  coincident  with  the  duration 
of  the  disease.  So  long  as  the  patient  remains  syphihtic  (page 
132)  he  bears  within  the  active  infectious  agent  of  the  disease. 
Yet  this  is  far  from  implying  a  continuance  of  infectiousness 
(page  61). 

It  may  still  be  true  that  the  essential  difference  between  a 
tertiary  lesion  and  a  secondary  one  is  that  "the  former  is  the 
product  of  some  tissue-destructive  chemical  agent  (toxin) 
plus  the  spirocheta,  while  the  latter  is  due  to  the  protpzoon 
only;  but  this  is  pure  speculation. 

But  if  primary,  secondary,  and  tertiary  lesions  are  all  caused 
by  the  same  living  parasite,  present  and  active  in  the  host  even 
during  long  years  of  apparent  health,  we  may  well  conclude 
that  some  serum  reaction  indicative  of  its  presence  might  be 
devised  (and  pray  for  its  advent),  and  we  may  ask  what  causes 
the  relapse  of  symptoms. 

Cause  of  Relapses :  Trauma  and  Syphilis.  —  Every 
theory  of  syphilis  invokes  local  trauma  or  general  debility  as 
the  cause  of  relapse,  and — broadly  speaking — the  rule  holds 
true  enough.  The  effect  of  trauma  in  evoking  syphilitic 
lesions  is  daily  exemplified  by  the  smokers'  mouth.  Some  pa- 
tients, however  thoroughly  treated,  cannot  smoke  even  one 
cig'ar  a  day  without  suffering  repeated  relapses  of  mucous 
patches  and  ultimately  having  tertiary  glossitis.  In  a  similar 
way,  skin  lesions  often  relapse  in  situ,  and  trauma  to  bone  fre- 
quently starts  a  node  or  a  gumma.  Thus  I  have  known  a 
horse  kick  to  be  the  cause  of  an  enormous  gumma  of  the  femur. 
Twice  I  have  seen  the  application  of  a  plate  of  false  teeth  to 
the  upper  jaw  promptly  followed  by  perforation  of  the  hard 
palate.  And  every  now  and  then  one  hears  of  a  syphilitic 
bone  lesion  following  fracture. 

1  Or  of  some  other  microorganism  of  which  5".  pallida  is  one  of  the  mani- 
festations. 


THE    NATURE   OF   SYPHILIS  39 

Y€t  this  is  by  no  means  the  whole  story,  I  can  call  to  mind 
two  persons  (one  of  them  a  woman)  who  never  had  smoked, 
and  yet  suffered  severe  and  prolonged  mouth  lesions.  Indeed, 
the  vagueness  of  our  knowledge  on  this  point  is  demonstrated 
by  our  inability  to  prophesy  relapses  with  any  certainty.  The 
washerwoman  and  the  baseball  player  are  not  peculiarly  sub- 
ject to  palmar  eruptions,  nor  the  microscopist  to  iritis,  nor  the 
athlete  to  periostitis.  Surgical  wounds  rarely  become  syphi- 
litic ;  bruises  and  fractures  often  do. 

There  are  probably  two  other  elements  in  the  equation : 
the  inherent,  congenital  susceptibility  of  the  patient's  various 
tissues  (which  makes  one  patient  prone  to  skin  lesions,  another 
to  brain  lesions,  etc.)  and  the  rate  of  growth  of  the  spirocheta. 
This  latter  variant  is  perhaps  influe^iced  by  the  patient's  gen- 
eral condition ;  for  close  questioning  often  reveals  the  fact 
that  a  relapse  due  to  no  apparent  cause  has  follozued  a 
period  of  mental  depression ;  stress,  or  grief  obviously  cal- 
culated to  depress  the  vital  resistance  of  the  tissues,  and  thus 
to  permit  more  rapid  multiplication  of  any  parasites  in  the 
body. 

But  when  a  relapse  of  symptoms  does  occur,  if  no  treat- 
ment is  administered,  further  relapses  in  various  parts  of  the 
body  are  almost  inevitable.  The  renewed  virulence  of  the  dis- 
ease is  not  localized,  but  general.  It  may  even  spread  in  spite 
of  vigorous  treatment.  Indeed,  a  vigorous,  rebellious  relapse 
of  syphilis  after  years  of  quiescence  is  one  of  the  most  mys- 
terious phenomena  a  physician  ever  witnesses. 

Examples  are  common  enough ;  let  the  following  suffice : 

Case  VIII. — A  patient  who,  after  a  few  early  symptoms  and 
adequate  treatment,  has  remained  well  twelve  years,  develops  a 
severe  neuralgia  of  the  right  arm.  This  lasts  several  months, 
and  is  almost  well,  though  no  antisyphilitic  medication  has  been 
given,  when  a  typical  gummatous  periostitis  brings  him  to  me. 
This   yields   rapidly  to  mixed  treatment,   but  six  months  later 


40 


THE    NATURE    OF    SYPHILIS 


relapses.  Again  it  is  promptly  cured,  and  remains  well  two 
years. 

Case  IX. — Another,  a  chronic,  steady  drinker,  whose  disease 
is  four  years  old,  well  treated,  and  who  has  had  no  symptoms 
whatever  since  the  first  eruption,  develops  gumma  of  the  nasal 
septum.  This  he  neglects  for  a  year,  when  a  large  gumma  sud- 
denly appears  on  the  right  parietal  bone.  He  promptly  takes 
treatment,  and  within  six  weeks  is  entirely  well.  Yet,  while 
continuing  his  treatment,  a  few  weeks  later  he  develops  simul- 
taneously an  interar3tenoid  edema  (causing  aphonia)  and  a 
chancre  redux.  The  former  yields  only  after  six  weeks  of  the 
most  vigorous  treatment.  The  latter  continues  as  a  little,  indu- 
rated lump  for  six  months.  Then  he  has  two  attacks  of  vertigo, 
due  probably  to  cerebral  syphiHs.  (Neurologists  differ  as  to  the 
exact  condition.) 

« 
Such  a  train  of  circumstances  (and  it  is  much  commoner 

than  the  occurrence  of  an  isolated  lesion  due  to  trauma)  shows 
that  a  tertiary  outbreak  is  rather  a  general  reaction  than  a  local 
one,  and  attacks  a  certain  spot  rather  because  it  offers  less 
resistance  (w^hether  on  account  of  previously  existing  syphilitic 
inflammation,  trauma,  or  some  cause  unknowai)  than  because 
there  is  an  actual  local  deposit  of  syphilitic  virus  in  that  spot 
already. 

The  Cause  of  Parasyphilids.  —  The  parasyphilids  are  ap- 
parently due  to  some  form  of  toxemia.  The  fact  that  other  tox- 
emias, such  as  alcohol  and  lead-poisoning,  produce  similar 
effects  argues  for  this  conclusion,  while  the  rule  that  parasyph- 
ilids are  rarely  associated  with  active  tertiary  lesions  and 
occur  quite  frequently  in  cases  that  have  shown  no  tertiary 
lesions  suggests  the  thought  that,  doubtless,  the  syphilitic  tox- 
emia which  produces  parasyphilids  is  related  to  the  z'inis 
vivum  of  the  primary  and  secondary  lesions  rather  than  to 
that  of  the  tertiary  symptoms.  Moreover,  the  toxemia  is  usu- 
ally a  mixed  one ;  partly  syphilitic,  partly  alcoholic,  or  contrib- 
uted to  by  some  other  poison. 


IMMUNITY 


IMMUNITY 


41 


Is  there  a  personal  immunity  from  syphilis?  Though  the 
question  is  a  vital  one,  it  has  never  been  answered.  Clinically, 
a  certain  proportion  of  those  exposed  to  syphilis  do  not  con- 
tract it;  but  this  is  due  to  the^ protection  of  an  unbroken  integu- 
ment. Inoculation  experiments  made  upon  man  have  occa- 
sionally failed,  and  it  has  been  inferred  that  these  failures  were 
due  to  a  natural  immunity.  Perhaps  it  was  because  the  sub- 
jects were  already  syphilitic. 

Various  general  phases  of  immunity  merit  consideration. 
Such  are  racial  immunity,  immunity  conferred  by  syphilis,  and 
the  relative  Immunity  of  Women. 

Racial  Immunity. — Negroes,  though  utterly  careless  about 
treatment,  are  relatively  immune  to  syphilis,  and  rarely  exhibit 
parasyphilitic  lesions.  This  fact,  accepted  in  our  Southern 
States,  has  also  been  noted  by  Livingstone  in  Africa.^  The 
inhabitants  of  Iceland,  Greenland,  and  Newfoundland  are  said 
to  be  ecjually  blessed.  On  the  other  hand,  other  races  not 
only  readily  fall  victims  to  this  plague,  but  also  show  a  pecul- 
iar vulnerability  when  first  attacked.  Thus  syphilis,  when  in- 
troduced among  the  South  Sea  Islanders  by  Captain  Cook's 
sailors,  is  alleged  to  have  attacked  the  poor  natives  with  fiend- 
ish virulence,  although  nowadays  their  descendants  suffer  no 
more  from  the  disease  than  the  rest  of  the  world. 

Whether  there  is  any  foundation  for  the  belief  that  syphilis 
acquired  by  a  European  from  an  Indian  or  a  Chinese  is  the 
more  virulent  because  of  its  origin  would  be  difficult  to  prove. 
Certainly  the  few  cases  I  have  seen  imported  from  Cuba,  Porto 
Rico,  China,  and  Japan  happen  to  have  been  rather  mild.  Yet 
some  authorities  allege  that  the  ravages  of  syphilis  at  the  end 
of  the  fifteenth  century  were  due  to  the  fact  that  the  new  species 

*  Hirsch's  Handh.  d.  Hisior-geogr.  Pathologie,  1883,  vol.  ii,  p.  25. 


42 


THE    NATURE   OF   SYPHILIS 


of  syphilis  imported  by  Columbus's  sailors  from  the  American 
aborigines  was  peculiarly  noxious  to  Europeans,  although  they 
were  already  pretty  well  immunized  by  heredity  against  some 
other  species  of  the  disease  handed  down  to  them  by  their  own 
forefathers. 

Is  Our  Race  Immunized? — But  this  amusing  speculation 
suggests  a  point  of  intense  practical  interest.  If  our  fore- 
fathers became  immune  to  one  species  of  syphilis,  shall  not  we 
become  immune  to  another?  And  is  not  syphilis  perhaps 
milder  in  this  generation  than  in  the  preceding  ones?  Assur- 
edly, one  might  answer,  if  we  were  ever  to  attain  a  racial 
immunity  against  syphilis  we  should  have  acquired  it  ere  this. 
For  twelve  generations  all  Europe  has  been  steeped  in  syphilis, 
and  it  is  to-day  the  greatest  plague,  except  tuberculosis,  of 
civilized  nations.  No,  syphilis  is  not  dying  out;  but  it  is, 
thank  God,  becoming  milder.  And  the  reason  it  is  becoming 
milder  is  that  it  is  being  better  treated. 

For  example,  among  the  cases  of  tertiary  syphilis  treated 
in  this  office  previous  to  1880,  94  are  known  to  have  received 
at  least  eighteen  months'  early  treatment,  while  109  had  been 
treated  less  than  a  year.  In  the  next  decade  the  proportion  was 
107:88,  and  since  1890,  138:53.^  Or,  to  express  the  same 
figures  more  concretely:  Before  1880,  forty-five  per  cent  of 
these  cases  were  treated  at  least  eighteen  months ;  in  the  next 
decade,  sixty  per  cent;  and  since  then,  seventy-two  per  cent. 
And,  although  prolonged  treatment  is,  unhappily,  not  alto- 
gether synonymous  with  intelligent  treatment,  still  the  diminu- 
tion in  the  intensity  and  duration  of  the  tertiary  lesions  of 
syphilis  in  this  generation  is,  I  believe,  due  to  a  progressively 
increasing  application  of  intelligent  hygiene  and  therapeutics 
to  the  disease  rather  than  to  any  progressive  immunity. 

1  In  most  cases  of  ancient  syphilis  it  is  impossible  to  learn  accurately  the 
nature  and  duration  of  early  treatment;  hence  the  relative  smallness  of  all  these 
figures. 


THE    SECOND    ATTACK    OF    SYPHILIS  43 

THE  SECOND  ATTACK  OF  SYPHILIS 

In  a  recorded  office  experience  of  over  two  thousand  cases 
of  syphilis  and  an  unrecorded  hospital  experience  of  far  more 
than  as  many  again,  neither  my  father  nor  I  have  encountered 
an  authentic  case  ^  of  a  second  attack  of  syphilis.  Our  expe- 
rience, therefore,  convinces  us  that  a  single  attack  of  syphilis 
confers  immunity  that  lasts  an  ordinary  lifetime.  It  were, 
however,  quite  as  absurd  to  insist  that  this  immunity  must  last 
a.Hfetime  as  to  insist  that  syphilis  is  incurable.-  All  that  one 
can  safely  allege  is  that  there  is  only  an  infinitesimal  danger 
of  error  in  assuring  one's  patients  that  syphilis  boasts  a  soli- 
tary virtue,  viz.,  having  acquired  it  once  they  will  never  ac- 
quire it  again. 

How  is  it,  then,  that  almost  every  syphilographer  can  re- 
call numerous  instances  of  reinfection  with  syphilis?  How 
is  it  that  such  a  collection  of  cases  as  Koebner's  ^  can  be  gath- 
ered from  reports  made  within  a  few  years  of  one  another? 
The  chief  reason  is  that  there  is  a  very  common  tertiary  lesion 
of  the  penis,  the  so-called  chancre  redux,  which  mimics  in  every 
detail  the  original  chancre.  This  is  best  exemplified  by  a  re- 
cital of  cases.  For  example,  Lang,*  who  believes  reinfection 
common  enough,  cites  the  following  instance  of  reinfection  in 
a  case  of  hereditary  syphilis : 

*  And  only  two  probable  instances. 

2  The  duration  of  immunity  is  to  some  minds  an  evidence  of  the  duration 
of  the  disease.  "Since  the  syphilitic  remains  forever  immune  to  syphilis,  he  is 
forever  liable  to  new  outbreaks  of  the  disease."  As  well  might  we  say  that, 
since  an  attack  of  small -pox  confers  an  immunity  that  usually  lasts  a  lifetime, 
the  immune  is  still  a  sufferer  from  small -pox.  The  converse  proposition,  how- 
ever, that  in  the  present  state  of  our  art  a  second  attack  of  syphilis  is  the  only  pos- 
sible proof  that  the  patient  has  recovered  from  his  first  attack  is  unimpeachable. 

^  Berlin,  klin.  Wochenschr.,  1872,  vol.  xlvi,  p.  549 

^  Pathol.  «.  Therap.  d.  Syph.,  1896,  p.  103.  The  reinfection  of  a  hereditary 
syphilitic  is,  of  course,  no  more  and  no  less  probable  than  when  the  first  infection 
is  acquired  by  extra-uterine  contagion. 


44 


THE    NATURE    OF    SYPHILIS 


Case  X. — :A  waiter,  whose  father  was  syphilitic  and  whose 
mother  had  died  in  childbirth,  stated  that  he  was  the  youngest 
of  a  number  of  children,  none  of  whom  had  lived  more  than  a 
few  months.  He  remained  well  till  sixteen  years  of  age,  and 
then  developed  an  ulcer  on  the  right  leg.  This  was  cured  by 
inunctions  and  iodid  of  potash.  Two  years  later  he  lost  his  uvula 
by  ulceration,  and  was  again  treated  by  iodid.  He  then  remained 
well  until  his  twenty-fifth  year,  when,  a  few  weeks  after  coitus, 
he  developed  a  sore  on  the  penis.  Lang  diagnosed  this  as 
chancre,  noted  typical  syphilitic  scars  on  shin  and  soft  palate, 
and  observed  that  the  glands  in  the  right  groin  were  enlarged. 
In  three  weeks  the  ulcer  healed  under  mercurial  ointment,  and 
the  patient  was  never  seen  again. 

Compare  with  this  Koebner's  Case  VHI,  upon  which  he 
lays  the  greatest  stress  : 

Case  XI  (Koebner's  VIII). — A  man  of  forty-five  has  syphilis 
in  1866,  and  his  wife  an  ulcerated  tubercular  syphilid  in  1867. 
In  1871  this  man,  having  had  intercourse  with  a  prostitute  ten 
weeks  previously,  with  his  wife  nine  and  nineteen  days  previously, 
exhibits  an  indurated  sore  on  the  penis.  No  enlargement  of  the 
inguinal  glands.  The  wife  remains  healthy.  The  sore  heals 
under  iodid  of  potash,  and  no  further  symptoms  develop. 

These  are  typical  instances  of  alleged  second  attacks  of 
syphilis — alleged  by  men  whose  experience  and  authority  are 
unquestioned.  Yet  they  found  their  diagnosis  of  reinfection 
upon  evidence  Mdiich  it  is  hoped  they  themselves  would  not 
consider  adequate  for  a  diagnosis  of  the  first  attack,  viz., 
chancre  alone,  whether  accompanied  by  adenitis  or  not.  My 
records  include  over  fifty  cases  of  chancre  redux  (page  482), 
and  though  many  of  them  simulated  the  initial  sore  in  every 
respect,  the  diagnosis  of  reinfection  was,  happily,  not  made 
in  any  instance. 

To  make  a  diagnosis  of  reinfection,  the  necessary  elements 
are  ( i )  sufficient  evidence  of  a  previous  attack  whether  in  the 
history  of  primary  and  secondary  lesions  sufficiently  clear  to 


SYPHILIS    IN    WOMEN  45 

exclude  the  possibility  of  error,  or,  better  still,  fortified  by 
characteristic  scars  of  tertiary  lesions.  Besides  this  there  must 
be  (2)  convincing  evidence  of  a  second  infection.  This  con- 
sists of  a  typical  chancre  with  characteristic  syphilitic  adenitis 
followed  by  unmistakable  secondary  lesions.  As  our  knowl- 
edge of  the  spirocheta  progresses  we  may  doubtless  add  as  a 
further  essential  the  identification  of  this  microorganism  in  the 
primary  or  secondary  lesions. 

Subject  to  such  close  scrutiny  the  c-ases  of  reinfection  with 
syphilis  are  surely  very,  very  few.^ 

SYPHILIS   IN  WOMEN 

Syphilis  is  a  far  milder  disease  among  women  than  among 
men.  Thus  my  records  show  that  among  207  women  18  never 
had  primary  or  secondary  lesions  sufficiently  marked  to  demand 
treatment,  and  could  not  when  their  tertiary  lesions  occurred 
recollect  any  early  symptoms  at  all.  This  does  not  necessarily 
imply  that  these  women  had  no  primary  or  secondary  lesions ; 
for  in  only  a  small  proportion  of  them  were  these  lesions 
searched  for  and  not  found  at  the  time  of  supposed  infection. 
But  it  is  in  marked  contrast  to  the  22  among  2,170  men  who 
did  not  recollect  their  early  symptoms.  Hence  among  women, 
nine  per  cent,  more  or  less,  have  primary  and  secondary  lesions 
so  mild  as  to  be  overlooked,  and  among  men,  only  one  per 
cent. 

The  same  general  rule  holds  good  throughout  the  disease. 
Women  are  far  less  liable  to  parasyphilids.  Thus  I  find  in 
my  records  only  three  cases  of  tabes  among  women  and  99 
among  men  (respectively  fifteen  per  cent  and  4.7  per  cent). 
However,  there  is  one  notable  exception  to  the  general  rule. 

*  Mile.  Contamine  has  recently  collected  thirty-five  cases  (These  de  Genes, 
1904)  and  Finger  relates  a  few  reinfections  in  hereditary  syphilis.  (Wien. 
klin.  Wochenschr.,  1900,  vol.  xiii,  p.  429.) 


46  THE    NATURE    OF    SYPHILIS 

Women  in  the  early  stages  of  syphilis  are  peculiarly  liable  to 
be  overwhelmed  by  the  general  toxemia ;  so  that,  whereas  male 
patients  rarely  show  grave  anemia  or  alarming  loss  of  weight, 
or  nervous  debility,  it  is  not  uncommon  for  women  to  be  com- 
pletely prostrated  by  the  systemic  infection  while  showing 
relatively  slight  local  signs  of  the  disease  (page  79). 

This  relative  immunity  from  syphilis  enjoyed  by  women, 
while  it  is  a  thing  to  be  thankful  for,  inasmuch  as  they  are  so 
frequently  innocent  victims  of  this  disease,  is  a  very  confusing 
factor  in  the  study  of  hereditary  syphilis.  For,  when  a  woman 
married  to  a  syphilitic  man  bears  a  syphilitic  child,  and  yet 
fails,  under  the  closest  scrutiny,  to  disclose  any  symptoms  of 
the  disease,  one  naturally  concludes  that  she  is  not  syphilitic. 
Indeed,  so  commonly  is  this  diagnosis  made  and  so  commonly 
do  these  women  in  later  years  break  out  with  tertiary  lesions  of 
syphilis,  that  the  ingenious  theory  has  been  evolved  of  infec- 
tion of  the  mother  through  the  child  (choc  en  ret  our)  ;  the 
chain  of  events  thus  being  infection  of  the  fetus  by  syphilitic 
semen,  infection  of  the  mother  by  the  syphilitic  fetus.  But 
if  vi'e  remember  that  a  very  large  proportion  of  women  have 
extremely  light  early  syphilis,  and  yet  have  tertiary  lesions  in 
later  years — women  who  have  never  been  married  or  borne 
children — the  chief  reason  for  this  roundabout  explanation  of 
paternal  syphilitic  heredity  is  removed.  (Contemplate  the  case 
of  an  apparently  healthy  mother  of  a  syphilitic  child,  whose 
inguinal  nodes  nevertheless  contained  spirochetse!) 

PATHOLOGY 

Syphilis  is  apparently  caused  by  the  Spirocheta  pallida,  and 
is  characterized  by  lesions  of  the  vessels  and  of  the  tissues  sur- 
rounding them,  excited  by  this  parasite.  Whether  the  lesions 
are  excited  by  the  parasite  directly  or  through  the  medium 
of  a  toxin  we  do  not  know,  though  the  latter  is  the  more 


PATHOLOGY  47 

probable  hypothesis.  Nor  is  it  yet  clear  whether  the  damage 
is  done  chiefly  through  the  lymph  vessels  and  spaces  or 
through  the  blood  capillaries.  The  facts  in  favor  of  the  for- 
mer theory  are : 

1.  The  ingress  of  spirochetae  at  the  point  of  inoculation 
into  the  lymph  spaces  or  lymph  vessels  of  the  skin  (Hoff- 
mann).^ 

2.  The  primary  endo-  and  perilymphangitis  observed  in 
chancre  (Hoffmann — though  Ehrmann  ^  believes  the  lym- 
phatic involvement  secondary). 

3.  The  marked  lymphatic  involvement  about  the  chancre 
and  the  early  satellite  and  general  adenitis. 

4.  In  the  later  lesions  the  possible  lymphatic  origin  of 
syphilitic  arterial  sclerosis  and  of  tabes  (Marie). 

On  the  other  hand,  the  facts  in  favor  of  hematogenous  ori- 
gin of  the  lesions  are : 

1.  The  manifest  and  marked  involvement  of  the  blood  capil- 
laries throughout  the  disease  from  the  chancre  to  the  latest 
visceral  lesion. 

2.  The  circulation  of  .S.  pallida  in  the  blood  at  an  early 
stage  in  the  disease. 

3.  The  lack  of  direct  evidence  that  the  late  vascular  lesions 
are  of  lymphatic  provenance. 

It  is  probable,  therefore,  that  the  primary  lesion  is  of 
lymphatic  origin,  the  later  lesions  of  vascular  origin. 

With  a  few  exceptions  (of  which  the  most  notable  are 
paresis,  tabes,  iritis,  and  the  macular  syphilid)  the  lesions  of 
syphilis  may  be  classed  as  perivascular,  granulomata,  i.  e.,  infil- 
trations of  the  vessel  walls  and  of  the  surrounding  tissue  with 
small,  round  cells  and  plasma  cells.  The  vessels  most  com- 
monly affected  are  the  capillaries. 

^  "  Die  Aetiologie  der  Syphilis,"  1906. 

2  Archiv  }.  Dermal,  u.  Syph.,  1904,  vol.  Ixviii,  p.  i. 


48 


THE    NATURE    OF    SYPHILIS 


Syphilis  is,  therefore,  classed  (with  tuberculosis  and  lep- 
rosy) among  the  infectious  granulomata. 

Lesions  of  the  Capillaries. — The  congestion  and  prolifera- 
tion shows  itself  by  dilatation  of  the  vessel  lumina,  swelling 


Fig.  I. — Ch.\xcre  of  the  PE^^[S.  (Zeiss  8  mm.,  comp.,  oc.  4.)  An  early  lesion 
>"dth  mantle  of  round  and  plasma  cells  about  vessels.  The  latter  are  increased 
in  number  and  show  an  endothelial  proHferation.  The  interv'ening  connective 
tissue  contains  hyperplastic  fibroblasts  and  a  few  plasma  cells  and  hmpho- 
cytes.    (Fordyce.) 

and  proliferation  of  the  endothelium,  and  formation  of  new 
capillaries.  Congestion  and  proliferation  also  occurs  in  the 
connective  tissue  surrounding  the  vessels^  as  a  reaction  to  the 
exudation    (Fig.   i). 

The  exudation  occurs  in  a  "  coat-sleeve "  fashion,  sur- 
rounding the  inflamed  vessels  with  a  zone  of  infiltrate  many 
times  the  diameter  of  the  vessel  itself.  This  zone  gradually 
merges  at  its  edge  into  the  surrounding  normal  tissue.    Groups 


PATHOLOGY 


49 


of  capillaries  are  usually  affected  and,  when  the  inflammation  is 
at  all  marked,  the  zones  of  infiltrate  merge  into  one  another 
to  form  an  irregular  area  more  or  less  widespread. 

The  exudate  consists  of  small  round  cells  and  plasma  cells, 
mingled  Avith  other  cells  (more  or  less  proliferated)  of  the  infil- 
trated tissue.     Here  and  there  a  giant  cell  ^  is  sometimes  seen. 


Fig.  2. — Symmetrical  Atrophy  of  the  Skin  with  Syphilis.  (Spencer  |  in. 
Zeiss  projection  oc.  2.)  Cross-sections  of  an  artery  and  a  vein.  The  former 
shows  a  proliferation  of  its  intima  and  adventitia  with  narrowing  of  the  lumen; 
the  latter  is  completely  occluded  by  intimal  proliferation.  Surrounding  them 
is  an  infiltration  of  round  and  plasma  cells.     (Fordyce.) 

These  giant   cells   are   neither  constant   nor  characteristic  of 
syphilis  (they  are  much  more  common  in  tuberculosis). 

The  reaction  of  the  exudation  upon  the  capillaries  them- 
selves is  most  important.     The  vessels  are  primarily 

'  /.  Am.  Med.  Ass'n.,  1907,  vol.  xlix,  p.  462. 


5° 


THE   NATURE    OF   SYPHILIS 


1,  Congested  and  proliferated  (see  above)  and  secondarily 

2.  Thrombosed,  "  their  former  site  being  marked  by  solid 
cords,  groups  of  irregularly  disposed  cells  with  pale  staining 
nuclei  and  giant  cells  with  peripheral  or  central  nuclei  or  both  " 
(Fordyce^).  Without  discussing  further  the  disputed  origin 
of  the  giant  cells,  one  may  recognize  that  many  of  them  are 
due  to  this  capillary  degeneration  (Fig.  2). 


Fig.  3. — Tubercular  Syphilid  of  the  Face.  (Spencer  ^  in.,  Zeiss  comp.  oc. 
4.)  Showing  obliteration  due  to  endothelial  proliferation  and  mantling  of 
transformed  vessels  by  round  and  plasma  cells.     (Fordyce.) 

As  a  result  of  the  thrombosis  and  destruction  of  the  vessels, 
the  infiltrated  zones  may  be  mottled,  showing  amid  the  cellular 
exudate  lighter  areas  representing  the  degenerated  capillaries 
(Fig.  3).     Moreover,  when  this  vascular  degeneration  is  ex- 


*  /.  Am.  Med.  Ass^n,  1907,  vol.  xlix,  p.  462. 


PATHOLOGY  51 

tensive,  there  is  macroscopic  necrosis  of  tissue  on  the  exposed 
surface  or  in  the  center  of  the  lesion.     Hence  the  erosion  of 
chancre,  the  desquamation  of  the  syphiHtic  papule,  the  ulcera- 
tion of  the  tubercular  syphilid,  and  the  caseation  of  gumma. 
Three  types  of  cellular  exudate  may  be  distinguished,  viz. : 

1.  The  diffuse  exudate  caused  by  an  acute,  intense  syphilitic 
infection  in  a  soil  of  little  resisting  power.  This  is  seen  char- 
acteristically in  the  visceral  lesions  of  hereditary  syphilis.  A 
whole  lobe  of  liver  (page  506)  or  lung  (page  462)  is  infil- 
trated; there  is  practically  no  tendency  to  localization  of  the 
exudate  or  to  central  degeneration  (gumma)  ;  all  the  vessels 
are  involved. 

2.  The  circumscribed,  mild,  multilocular  exudate  with  no 
tendency  to  central  degeneration,  but  with  a  marked  tendency 
to  spontaneous  resolution.  Such  are  the  ephemeral  lesions  of 
secondary  acquired  syphilis. 

3.  The  circumscribed,  grave,  malignant  lesions  of  tertiary 
syphilis  (whose  characteristics  are  shared  in  a  less  degree  by 
the  chancre),  of  which  the  gumma  is  the  type.  These  tertiary 
or  gummatous  lesions  thus  consist  in  dense  perivascular  exu- 
dates with  central  degeneration  (caseation)  due  to  vascular 
obstruction  and  obliteration  in  the  periphery  of  the  lesion. 

Disposition  of  the  Spirochetae. — In  hereditary  syphilis  the 
spirochetse  are  found  in  the  capillaries  both  at  the  site  of  lesions 
and  where  no  pathologic  change  is  discernible. 

In  the  pathologic  exudate  they  are  present  in  great  num- 
bers (Plates  II,  III). 

In  acquired  syphilis  they  are  numerous  in  the  tissues  infil- 
trated by  secondary  lesions,  extremely  rare  in  the  tertiary 
lesions  (page  29). 

Lesions  of  the  Larger  Vessels. — Of  the  larger  vessels  the 
arteries  are  much  the  most  commonly  affected  by  syphilis,  the 
veins  less  often,  the  lymphatics  least  of  all. 

The  lesions  are  comparable  to  those  that  occur  in  the  capil- 


52  THE    NATURE    OF   SYPHILIS 

laries,  i.  e.,  exudation  into  and  about  the  vessel  with  obHtera- 
tion  and  degeneration  as  its  terminal  stage.  Indeed,  some 
larger  vessels  are  often  involved  in  the  capillary  lesions  de- 
scribed above.  But  the  typical  syphilitic  lesions  of  the  large 
vessels,  especially  the  arteries,  derive  their  importance  rather 
from  the  lesions  of  the  vessels  themselves  than  from  those  of 
the  surrounding  tissues. 

The  "  coat-sleeve  "  infiltrate  is  seen  about  small  vessels ; 
but  this  systematic  disposition  of  the  exudate  diminishes  pro- 
gressively in  proportion  to  the  size  of  the  vessel  attacked  until, 
in  the  aorta,  the  lesions  are  usually  patches  distributed  over  the 
circumference  of  the  artery,  but  showing  no  definite  tendency 
to  surround  it  (page  487). 

The  changes  in  the  walls  of  the  larger  arteries  are  most 
common  and  have  been  best  studied  in  the  arteries  of  the  brain 
(page  373).  Whether  these  changes  usually  begin  in  the  in- 
tima,  as  Heubner,  their  discoverer,  supposed,  or  in  the  adven- 
titia,  as  is  now  generally  believed,  they  spread  around  and 
along  the  vessel  in  the  form  of  a  round  cell  exudate,  usually 
involving  the  adventitia  rather  more  than  the  intima,  but  in 
large  measure  sparing  the  muscular  tissue  of  the  media.  Ac- 
tual gummata  may  occur  in  the  adventitia.  Thus  the  wall  of 
the  vessel  is  thickened,  its  elasticity  lessened,  its  intima  con- 
gested and  roughened.  Hence  in  the  smaller  arteries  the  clin- 
ical result  of  syphilitic  inflammation  is  usually  thrombosis  or 
obliteration,  less  often  rupture  or  aneurysm,  while  in  the  aorta 
aneurysm  is  the  clinical  manifestation  of  the  disease. 

Let  this  brief  resume  of  the  pathology  of  syphilis  suffice  not 
to  exhaust  the  subject,  but  to  impress  upon  the  reader  the  unity 
of  the  phenomena  of  syphilis,  be  it  hereditary  or  acquired,  pri- 
mary, secondary,  or  tertiary.  The  gross  pathology  of  gumma, 
etc.,  is  best  considered  in  relation  to  the  various  regions  in- 
volved. 


CHAPTER    V 
TRANSMISSION  OF  SYPHILIS 

Recent  experimental  investigations  upon  monkeys  have 
confirmed  in  large  measure  the  accepted  theories  of  syphilitic 
infection. 

We  have  learned  that  the  spirocheta  is  the  infectious  agent, 
and  that  infection  is  most  common  from  the  chancre  and  the 
secondary  lesions.  But,  inasmuch  as  rather  intimate  contact 
with  the  secretions  of  a  syphilitic  lesion  is  essential  to  infec- 
tion, it  is  probable  that  of  the  secondary  lesions  only  the  moist 
papules  and  ulcers  are  clinically  infectious.  Dry  secondary 
lesions,  as  well  as  all  tertiary  lesions,  do  not  transmit  the 
spirocheta  even  though  they  contain  it  (page  36). 

There  has  always  been  question,  however,  of  the  virulence 
of  the  secretions  of  the  syphilitic,  notably  his  semen,  and  also 
of  the  virulence  of  his  blood,  notably  in  reference  to  surgical 
operations.  That  the  secretions  may  be  virulent  is  proven  by 
the  discovery  of  spirocheta  in  the  nares  (Levaditi),  on  the 
conjunctiva  (Bab),  in  the  epithelium  of  the  bowel  and  of  the 
kidney  in  hereditary  syphilis,  while  a  monkey  has  been  infected 
by  the  apparently  normal  semen  of  a  syphilitic  man. 

Whether  in  each  of  these  instances  some  minute  syphilitic 
lesion  was  present  and  accounted  for  the  exudation  of  spiro- 
chetse  is  a  purely  academic  question.  The  clinical  fact  re- 
mains that  the  overwhelming  infection  of  severe  hereditary 
syphilis  may  produce  an  infectiousness  of  all  the  apparently 
normal  secretions ;  while  in  acquired  syphilis  the  apparently 
normal  semen  may  be  infectious, 

53 


54 


TRANSMISSION    OF    SYPHILIS 


That  infection  from  such  sources  must  be  rare,  however, 
is  shown  by  the  numerous  faihires  of  inoculations  made  with 
mothers'  milk,  with  urine,  with  semen,  etc. ;  and  the  danger 
of  such  infection  is  probably  extremely  small  unless  from  the 
prolonged  contact  possible  in  seminal  transmission. 

The  danger  of  infection  from  syphilitic  blood  is  even 
slighter.  The  spirochetse  are  few  in  the  blood  and  are  present 
only  in  the  most  fluid  stage  of  the  disease.  The  real  danger 
of  infection  with  syphilis  lies  in  the  mucous  ulcer  or  papule, 
which  may  exist  unsuspected  and  even  undiscoverable  about 
the  mouth  or  genitals,  though  its  infectiousness  is  undimin- 
ished by  its  insignificant  size. 

Whether,  as  has  been  alleged,  a  clean  woman  may  act  as 
an  intermediary  host  and  convey  the  virus  from  a  syphilitic 
partner  to  a  clean  one,  and  yet  escape  infection  herself  would 
be  hard  to  prove,  though  such  an  accident  is  eminently  possi- 
ble. Sexual  contact  with  a  person  supposed  to  be  clean  is 
surely  often  the  occasion  of  a  syphilitic  infection ;  less  often  the 
infection  is  extragenital  and  non-sexual. 

EXTRAGENITAL   AND   NON-SEXUAL   INFECTION 

Though  syphilis  occurs  in  all  lands  and  at  all  ages,  it  is 
relatively  much  more  common  in  some  countries  than  in  others. 
Thus  in  some  of  the  Balkan  states  and  in  certain  parts  of  Rus- 
sia and  Asia  Minor,  in  many  tropical  countries,  and  in  certain 
isolated  communities  syphilis  is  practically  endemic.  Every- 
one has  the  disease,  and  it  is  transmitted  fully  as  commonly 
by  extragenital  as  by  genital  contact.  In  the  United  States, 
however,  the  disease,  though  universally  distributed,  probably 
affects  a  smaller  proportion  of  the  community  than  in  most 
countries;  and,  inasmuch  as  we  do  not  indulge  in  kissing  and 
other  forms  of  personal  endearment  so  much  as  our  European 
neighbors,    extragenital    infections    are    relatively   uncommon 


EXTRAGENITAL    AND    NON-SEXUAL    INFECTION 


55 


among  us.  Fournier  estimates  that  in  France  syphilis  is  ac- 
quired through  sexual  intercourse  in  from  ninety  to  ninety- 
three  per  cent  of  all  cases.  In  this  country  the  proportion  is 
probably  higher.  Inasmuch  as  the  initial  symptom  of  syphilis 
— the  chancre — occurs  at  the  point  of  inoculation,  the  propor- 
tion between  genital  chancre  and  extragenital  chancre  may  be 
taken  as  fairly  indicative  of  the  frequency  of  sexual  infection.^ 
Montgomery-  finds  5.5  per  cent  of  extragenital  infections 
among  1,217  cases;  I  find  a  little  less  than  four  per  cent  in 
2,400  cases.  Montgomery  adds  the  following  data :  Bulkley 
(New  York),  5.5  per  cent;  Finger  (Vienna),  1.3  per  cent; 
Wracek  (Vienna),  7.5  per  cent;  Van  Walsen  (Amsterdam), 
8.5  per  cent;  Fournier  (Paris),  and  Broich  (Germany),  9 
per  cent;  Krefting  (Christiania),  15.6  per  cent;  Russia,  75 
to  80  per  cent. 

Among  some  2,200  syphilitic  men  I  find  but  70  instances 
of  extragenital  chancre;  while  among  207  syphilitic  women,  21 
showed  or  gave  history  of  extragenital  chancre.  This  propor- 
tion— about  3.5  per  cent  for  men  and  ten  per  cent  for 
women  ^ — confirms  the  accepted  belief  that  women  are  more 
often  innocently  contaminated  than  men,  while  the  method  of 
contamination  is  sufficiently  indicated  by  the  following  table, 
in  which  practically  all  chancres  of  lip,  tongue,  and  tonsil 
were  due  to  kissing,  while  almost  all  the  finger  chancres  in 
men  occurred  in  doctors  and  were  due  to  vaginal  examination, 
only  one  of  them  being  attributed  to  infection  during  a  surgi- 
cal operation.  The  breast  chancres  were  acquired  by  nursing 
syphilitic  infants.     A  chancre  of  tongue  or  tonsil  may  surely 

'  Buchler,  "Report  of  New  York  Presbyterian  Hospital,"  1906,  vol.  vii, 
p.  105. 

'J.  Ciilan.  Diseases,  August,  1905. 

■'  Fournier  has  tabulated  10,000  chancres  (96  per  cent  of  them  in  men),  of 
which  94  per  cent  were  genital  in  man,  and  only  63  per  cent  in  women. — They 
kiss  everyone  in  France. 


56 


TRANSMISSION    OF    SYPHILIS 


be  acquired  by  simple  lip  contact  with  an  infected  surface,  just 
as  urethral  chancre  may  result  from  normal  coitus. 


EXTRAGENITAL   CHANCRE 


TABLE   I 


Male. 


Finger 

Lip 

Tongue... 
TonsiL... 
Abdomen. 

Cheek 

Chin 

Eyelid 

Arm 


70  cases 

34     " 
24     " 

4     " 


2 

I  case 


Female. 


Lip 

Finger 

Vaccination . 

Breast 

Tonsil 

Eyelid 


21 

cases 

13 

" 

2 

u 

2 

11 

2 

it 

I 

case 

I 

u 

Dr.  Bulkley  has  collected  from  various  sources  a  larger 
table  of  extragenital  chancres,  showing  their  distribution  as 
they  are  likely  to  occur  in  general  practice,  with  the  exception 
that  vaccination  and  other  surgical  operations  are  no  longer 
common  causes. 


TABLE    II 


Lip 1,810  cases 

Breast  and  nipple 1,148     " 

Buccal  cavity 734 

Fingers  and  hand 462 

Eyelids  and  conjunctivas  372     " 

Tonsils 307 

Throat    (deep    oral    and 

nasal) 264 

Tongue 157     " 

Chin 146     " 

Cheek 145     " 

Trunk 100     " 

Nose : 95 

Anus 87 


Perigenital  region 77  cases 

Legs  and  thigh 73     " 

Forearm 59 

Neck 47     " 

Gums 42 

Forehead  and  temple 37 

Ears 27 

By  vaccination 1,863 

By  cupping  and  phlebot- 
omy    745 

By  circumcision 1 79     " 

By  tattooing 82     " 

Total 9,058     " 


Among  the  lower  classes  extragenital  chancres  are  much 
more  frequent  than  among  the  wealthy,  and  occur  in  curious 


EXTRAGENITAL   CHANCRE  57 

locations  because  of  strange  methods  of  infection.  Thus  I  find 
recorded  the  case  of  a  young  woman  who  developed  a  chancre 
on  the  forearm  from  carrying  an  infant  with  mucous  patches 
and  condylomata  about  the  anus. 

It  is  quite  futile  to  attempt  a  classification  of  the  various 
ways  by  which  syphilis  has  been  or  might  be  transmitted  out- 
side of  sexual  relations.  We  still  occasionally  hear  of  little 
epidemics  caused  by  physicians,  or  by  midwives  whose  infected 
fingers  spread  the  disease,  while  mediate  contagion  caused  by 
infection  from  some  object  by  which  the  secretion  of  a  puru- 
lent syphilitic  sore  has  been  recently  deposited  is  the  cause  of 
sporadic  outbreaks.  Thus  Fournier  narrates  cases  of  infec- 
tion transmitted  to  a  child  by  its  uncle  who  blew  his  syphi- 
litic child ;  and  this  exception  is  fully  compensated  for  by  3 
other  case  in  which  a  kindly  lady  bound  up  the  scratched 
knee  of  a  little  child  with  her  handkerchief  saturated  with 
saliva.  One  of  my  cases  of  mouth  infection  was  attributed 
to  sucking  a  pencil  known  to  have  been  previously  used  by 
a  man  in  florid  syphilis.  Epidemics  have  been  caused  by 
dental  instruments,  obstetrical  instruments,  Eustachian  cath- 
eters, blowpipes,  and  anything  which  may  pass  from  one 
mouth  to  another,  such  as  pipes,  cigars,  cups,  spoons,  etc. 
In  a  few  instances  washerwomen  have  been  infected  by  clothes 
befouled  with  virus.  Vaccination  syphilis  and  circumcis- 
ion syphilis  have  been  abolished  by  the  elimination  of  human 
vaccine  and  of  the  orthodox  sucking  of  the  circumcision 
wound. 

The  practical  conclusion  to  be  drawn  from  what  we  know 
of  extragenital  syphilis  is  an  appreciation  of  the  danger  of 
taking  into  one's  mouth  anything  which  has  recently  been  in 
the  mouth  of  another,  or  of  kissing  not  wisely,  but  too  pro- 
miscuously (Cases  I  and  II,  page  4).  For,  unhappily,  syphi- 
lis may  be  transmitted  not  only  to  an  innocent  person,  but  also 
from  an  innocent  person — i.  e.,  from  one  who  does  not  know 


^8  TRANSMISSION    OF   SYPHILIS 

that  he  has  the  disease  or  who  thinks  that  its  active  manifesta- 
tions are  past. 

Although  the  disease  may  only  be  transmitted  by  inocula- 
tion of  the  secretions  from  the  primary  or  secondary  lesions, 
and  although,  theoretically  at  least,  the  possession  of  an  un- 
broken integument  protects  from  danger  of  infection  with 
syphilis,  one  can  never  be  absolutely  sure  that  a  patient  in  the 
first  two  or  three  years  of  syphilis  has  not  some  insignificant 
lesion  of  mouth  or  genitals  whose  presence  he  does  not  realize, 
nor  can  one  be  sure  of  an  absolutely  unbroken  integument.  It 
cannot  be  too  often  repeated — syphilis  is  frequently  trans- 
mitted by  a  person  who  believes  he  has  no  lesions  of  syphilis 
upon  him  to  a  person  who  believes  his  integument  intact. 

AGE  OF  INCIDENCE 

Syphilis  is  primarily  a  disease  of  young  adults.  I  have 
tabulated  1,775  cases  in  men  and  find  that  only  1.3  per  cent 
(excluding  hereditary  syphihs)  began  under  eighteen;  5.2  per 
cent  began  between  eighteen  and  nineteen;  55.2  per  cent  be- 
tween the  ages  of  twenty  and  twenty-nine;  17.9  per  cent 
between  thirty  and  thirty-four;  10.4  per  cent  between  thirty- 
five  and  thirty-nine;  5.8  per  cent  between  forty  and  forty- 
four;  and  4.2  per  cent  above  forty-five.  The  actual  percent- 
ages between  the  ages  of  eighteen  and  thirty-six  are  the  fol- 
lowing : 

18  years  old i.i  percent.  28  years  old 4.6  per  cent. 

19  "  "  3-3  "  "  29  "  "  4.3  "  " 

20  "  "  5-4  "■  "  30  "  "  5-1  "  " 

21  "  "  5-4  "  "  31  "  "  3-5  "  " 

22  "  "  5.6"  "  32  "  "  3.1"  " 

23  "  "  7.0"  "  I3  "  "  3.1"  " 

24  "  "  6.8  "  "  34  "  "  3.1  "  " 

25  "  "  5.9"  "  35  "  "  2.8"  " 

26  "  "  5.6"  "  36  "  "  1.9"  " 

27  "  "  4.6  "  " 


PROBABILITY   AND    POSSIBILITY   OF    INFECTION 


59 


Eighty  per  cent,  therefore,  begin  between  the  ages  of  nine- 
teen and  thirty-five. 

Among  prostitutes  the  average  age  of  incidence  is  about 
seventeen  years  (in  France),  while  reputable  women  usually 
acquire  syphilis  at  the  time  of  matrimony. 

THE  PROBABILITY  AND   POSSIBILITY  0^   INFECTION 

.  Nothing  is  certain  in  syphilis  except  its  uncertainty.  And 
if  at  the  outset  of  the  disease  we  are  unable  to  prophesy  what 
its  symptoms  will  be  or  whether  it  will  be  mild  or  severe,  still 
less  are  we  competent  to  state  when  a  given  case  will  cease  to 
be  infectious.  A  host  of  practical  queries  on  this  subject  are 
constantly  clamoring  for  answer.  For  example :  "  I  have  been 
exposed  to  syphilis ;  am  I  infected  ?  "  or,  "  I  have  exposed  an- 
other; is  he  infected?  "  or,  "  I  am  pregnant;  will  the  child  be 
syphilitic  ?  " 

Does  Exposure  Necessarily  Imply  Infection? — No; 
emphatically  not.  The  physician  who  has  the  confidence  of  his 
patients  will  occasionally  come  upon  cases  where  exposure,  even 
repeated  exposure,  has  not  resulted  in  infection.  I  have  re- 
cently seen  three  striking  instances  of  this. 

1.  A  married  man  who  cohabited  with  his  wife  constantly 
throughout  the  active  period  of  his  syphilis;  yet  she  was  not 
infected. 

2.  A  woman  who  cohabited  indiscriminately  with  three 
men,  one  who  had  infected  her  and  two  others;  but,  though 
she  had  various  lesions,  the  two  escaped. 

3.  A  woman  who  cohabited  almost  daily  with  a  man  dur- 
ing the  two  months  from  the  appearance  of  his  penile  chancre 
to  the  eruption  of  his  secondary  syphilis.  I  have  watched  her 
closely  for  a  year,  and  as  yet  she  shows  no  sign  of  syphilis. 

But  such  cases  by  no  means  tell  the  whole  story.  To  ac- 
quire syphilis  but  one  exposure  is  requisite.    A  syphilitic  lesion 


6o  TRANSMISSION    OF   SYPHILIS 

in  contact  with  an  abrasion,  however  minute,  and  the  deed  is 
done.  The  abrasion  need  be  only  microscopic,  the  lesion  unsus- 
pected, the  contact  momentary.  Indeed,  clinically,  any  one  of 
these  three  conditions  may  be  apparently  lacking. 

1.  It  is  exceptional  for  the  victim  to  remember  any  abra- 
sion at  the  time  of  inoculation. 

2.  As  a  rule,  examination  of  a  person  who  has  infected 
another  with  syphilis  reveals  infectious  lesions  in  considerable 
number;  but  occasionally  no  trace  of  syphilis  can  be  discerned. 
The  transmission  of  syphilis  by  patients  who  think  themselves 
clean  is  a  common  occurrence. 

3.  Exceptionally  it  is  impossible  to  identify  the  culpable 
contact.  No  history  of  exposure  is  obtainable;  yet  the  patient 
has  syphilis.  If,  under  such  circumstances,  genital  chancre 
exists,  the  patient's  veracity  may  fairly  be  doubted ;  but  if  the 
chancre  is  extragenital  the  mystery  remains  unexplained. 

What  is  the  Probability  of  Infection  from  Contact  by 
Kissing  or  Sexual  Intercourse  with  a  Person  Known  to  be 
Syphilitic? — This  question  cannot  be  answered  by  statistics. 
The  cases  quoted  above  prove  the  possibility  of  escape  under 
almost  any  clinical  circumstances,  while  the  converse  proposi- 
tion that  a  single  brief  contact,  even  if  followed  by  immediate 
and  thorough  washing,  may  prove  infectious,  is  daily  exempli- 
fied. The  only  attitude  permissible  for  a  medical  adviser  is 
one  of  complete  impartiality.  If  your  patient  has  been  exposed, 
calm  his  fears  without  too  much  fortifying  his  hopes,  and  bid 
him  wait  the  dreary  weeks  of  probation.  Examine  the  sus- 
pected partner,  if  possible,  but  do  not  put  absolute  reliance  upon 
the  positive  or  negative  results  of  such  an  examination. 

The  following  set  of  cases  related  to  me  by  Dr.  John  F. 
Connors  may  serve  as  an  example :  Eleven  men  were  repeatedly 
and  in  rotation  exposed  to  infection  from  a  single  woman. 
They  thought  themselves  well  and  she  was  not  obviously  dis- 
eased.    Yet  six  of  them  contracted  gonorrhea  and  chancroid, 


SYPHILIS   AND    MARRIAGE  6l 

four  syphilis  and  chancroid,  and  one  chancroid  alone.  Total, 
chancroid,  one  hundred  per  cent ;  gonorrhea,  fifty-five  per  cent ; 
syphilis,  thirty-six  per  cent. 

When  Does  Syphilis  Cease  to  be  Infectious?— Since 
the  probabilities  are  so  vague,  what  are  the  possibilities?  The 
question  is  by  no  means  easy  to  answer.  Certainly  eight  out 
of  ten  syphilitics  cease  to  be  infectious  within  three  years.  Cer- 
tainly 99  men  out  of  lOO  cease  to  be  infectious  within  four 
years.  Certainly  the  proportion  of  infections  from  syphilitics 
of  more  than  five  years'  standing  is  infinitesimal.  Yet  one 
cannot  expect  the  victim  to  care  whether  he  is  one  of  two  or 
one  of  a  million.  Mathematics  do  not  ameliorate  the  disease, 
and  a  five-year  old  syphilis,  if  it  infects  at  all,  infects  just  as 
virulently  as  a  fresh  case.  We  are  in  crying  need  of  some  cri- 
terion to  prove  that  the. last  spirocheta  in  a  given  patient  is 
dead,  and  that  need  is  not  yet  answered. 

SYPHILIS  AND   MARRIAGE 

My  records  of  marital  infections  have  some  bearing  upon 
this  point.  (I  include  only  those  who  took  no  precautions  to 
prevent  contamination.)  Among  2^  patients  who  acquired 
syphilis  when  married,  or  married  within  a  year  after  acquir- 
ing it,  25  infected  their  wives  (or  husbands)  and  only  2  did  not. 
Of  those  marrying  during  the  second  year  of  the  disease,  10 
proved  infectious,  4  not  so.  In  the  third  year  4  were  infec- 
tious, 16  not  so.  In  the  fourth  year  i  was  infectious,  4  not 
so.  Beyond  this  it  has  been  impossible  to  estimate  the  propor- 
tion of  those  who  escaped;  but  2  infections  are  recorded  in  the 
fifth  year  and  (an  alleged)   i  in  the  seventh. 

In  41  cases  it  is  certain  that  the  wife  was  infected  during 
the  first  year  of  exposure  (almost  all  during  the  first  few 
months).  In  one  case  the  husband's  syphilis  had  been  treated 
but  a  few  weeks,  and  was  three  years  old  when  he  married; 


62  TRANSMISSION    OF    SYPHILIS 

yet  the  wife  was  not  infected  until  one  year  later,  after  the 
birth  of  a  healthy  child  (last  seen  well  at  the  age  of  seven). 
The  second  child  was  born  syphilitic  four  years  after  matri- 
mony. No  other  instance  of  delayed  marital  infection  has  come 
under  my  notice  (page  68). 

Thus  the  danger  of  marital  infection  is  instant,  and  the 
chances  for  it  are  at  least  12  to  i  during  the  first  year  of  the 
disease,  5  to  2  in  the  second  year,  i  to  4  in  the  third  year,  and 
all  but  nothing  after  the  fourth  year — whether  the  patient  has 
been  well  treated  or  not. 

Most  practitioners  are  willing  to  assure  their  patients  that 
after  three  years  of  treatment  all  danger  of  transmitting  the 
disease  is  past.  Yet  this  is  by  no  means  an  absolute  rule. 
Though  none  of  my  cases  of  late  infection  was  derived  from 
patients  who  had  been  well  treated,  there  are  many  such  re- 
corded. Fournier  even  goes  so  far  as  to  state  that  though  the 
mercurial  treatment  of  early  syphilis  diminishes  the  danger  of 
tertiary  symptoms  in  proportion  to  its  thoroughness,  "  the  fre- 
quency of  late  secondary  (infectious)  manifestations  ^  increases 
in  proportion  to  the  duration  of  treatment."  While  I  cannot 
accept  this  conclusion,  it  is  impossible  to  deny  the  thesis  he 
has  so  forcefully  maintained  in  "  Syphilis  et  mariage  "  and 
"  Syphilis  secondaire  tardive  "  that  infection  may  occur  not 
only  after  a  thorough  course  of  treatment  and  after  the  third 
year  of  the  disease,  but  even  after  the  fifth,  the  tenth,  perhaps 
the  twentieth  year.  Tarnowsky  has  reported  ^  the  transmission 
of  syphilis  in  the  fifth,  sixth,  ninth,  tenth,  and  fifteenth  years. 
Neumann  ^  accepts  the  possibility  of  contagion  between  the 
fifth  and  the  tenth  year,  and  perhaps  later.  Fournier  relates 
three  infections  during  the  sixth  year,  one  in  the  seventh,  six 
in  the  eighth,  three  in  the  ninth,  two  in  the  tenth ;  but  at  this 

*  See  page  87. 

'  Third  Intemat.  Congress  of  Dermatology,  1896. 

^  Wien  nied.  Presse,  1899. 


SYPHILIS   AND    MARRIAGE  63 

point  even  Fotirnier  falters.  He  relates  cases  of  supposed  in- 
fection at  the  end  of  twelve,  thirteen,  and  seventeen  years ;  but 
confesses  that  "  in  view  of  the  complexity  of  the  subject  and 
the  great  possibility  of  error  in  so  delicate  a  matter,  these 
cases  are  as  yet  too  few  to  warrant  any  conclusion  being  drawn 
from  them." 

But  Fournier  is  an  extremist.  He  stands  almost  alone  in 
his  horror  of  late  infections.  Twenty  years  ago  he  acquiesced 
in  matrimony  at  the  end  of  five  years  of  syphilis;  to-day  he 
says :  "  If  my  son  contracted  syphilis,  I  should  not  permit 
him  to  marry  before  the  sixth  or  seventh  year  of  his  disease."  ^ 
We  can  afiford  to  be  a  little  milder  and  assert  that  matrimony 
is  often  safe  and  sometimes  justifiable  at  the  end  of  three 
years,  but  unless  the  social  elements  at  stake  are  very  great  it 
is  more  prudent  to  follow  the  rule  that  marriage  of  a  syphilitic 
is  permissible  only  after  five  years,  during  the  last  two  of  zvhich 
he  has  been  zvithout  symptoms  and  zvithout  treatment.  The 
occurrence  of  symptoms,  especially  if  they  be  secondary  symp- 
toms, after  the  third  year  of  the  disease  should  postpone  matri- 
mony until  two  years  have  elapsed  since  the  termination  of  the 
treatment  required  to  cure  these  symptoms. 

The  reason  for  requiring  two  years  of  health  is  this.  Late 
infections,  like  early  ones,  are  due  practically  always  to  con- 
tamination by  secondary  lesions  in  the  mouth  and  upon  the 
genitals.  Of  the  eighteen  cases  related  by  Fournier  in  which 
infection  occurred  between  the  sixth  and  seventeenth  years  of 
the  disease,  ten  were  buccal  and  eight  genital  infections.  Now 
these  lesions  are  likely  to  relapse  persistently  and  without  long 
intervals  of  health."  Consequently  the  lapse  of  two  years  with- 
out such  lesions  is  a  sufficient  guarantee  that  they  will  not  re- 
cur.     If  the  patient  is   an   inveterate  smoker,   he   should   be 

'  Bull,  de  la  soc.  franc,  de  prophylaxie  san.  et  mor.,  1906,  vol.  v,  p.  125. 
^Whereas  tertiary  non-contagious  lesions  often  relapse  after  many  years 
of  health. 


64  TRANSMISSION    OF   SYPHILIS 

warned  of  the  danger  of  relapsing  lesions  of  the  tongue  to 
which  his  habit  subjects  him  (page  130).  Curiously  enough 
several  patients  had  been  repeatedly  warned  of  this  danger  be- 
fore they  succeeded  in  infecting  their  wives  (see  Case  XVII, 
page  94). 

Finally,  be  it  remembered,  the  moral  aspect  of  this  ques- 
tion must  carry  fully  as  much  weight  as  the  physical.  To  pro- 
hibit matrimony  in  a  given  case  may  wreck  a  man's  life  even 
more  completely  than  syphilis  could  blast  his  wife's,  and 
though  this  consideration  can  have  no  force  in  the  first  two 
years  of  the  disease  when  infection  is  all  but  certain,  in  the 
fourth  and  fifth  years  one  may 'make  exceptions  for  adequate 
social  cause  and  with  due  precautions,  deeming  the  possibility 
of  infection  light  in  comparison  to  the  certain  despair  implied 
by  delay.  After  the  fifth  year  it  is  wiser  even  to  urge  matri- 
mony, for  nothing  so  completely  disarms  syphilis  of  its  terrors 
as  the  possession  of  a  calm  fireside,  a  happy  wife,  and  a  ruddy 
child.  Many  a  man  has  been  driven  to  this  happiness  like  a 
whipped  cur,  and  has  found  in  it  a  fullness  of  content  which 
the  medicines  and  maxims  of  no  physician  could  provide. 


.    CHAPTER    VI 
SYPHILITIC  INHERITANCE 
SYPHILIS  AND   MATERNITY 

Syphilis  in  woman  differs  from  syphilis  in  man  in  many 
respects,  but  nowise  more  than  in  its  infectiousness.  SyphiHs 
in  the  male  ceases  to  be  transmissible  to  wife  or  to  child  ^ 
within  five  years  in  practically  every  instance  and  under  any 
circumstances  of  neglect  and  inefficient  treatment.  But  syphi- 
lis in  woman,  though  it  ceases  to  be  transmissible  by  contact 
quite  as  early  as  in  man,  may  continue  transmissible  by  hered- 
ity for  an  indefinite  number  of  years.  Thus  syphilitic  children 
— aborted,  stillborn,  dying  in  infancy,  or  living  in  spite  of  the 
infection — may  follow  one  another  for  ten,  fifteen,  even  twenty 
years.  In  so  long  a  series  syphilis  plays,  as  might  be  expected, 
the  same  pranks  as  in  its  course  in  the  individual.     Thus : 

1.  Most  exceptionally,  the  woman  recently  infected  with 
syphilis  and  untreated  may  bear  only  healthy  children. 

2.  As  a  rule,  the  recently  infected  woman  bears  at  least 
one  syphilitic  child,  but,  if  well  treated  (probably)  bears 
healthy  ones  thereafter. 

3.  If  not  treated,  she  usually  has  several  miscarriages  be- 
tween the  fourth  and  seventh  months,  two  or  three  children 
who  die  at  birth  or  within  the  first  three  months  of  their  lives, 
and  others  who  survive — syphilitic. 

In  general,  the  children  are  less  and  less  infected  as  time 

'  Unless  we  accept  the  theory  of  paternal  heredity,  the  reasons  for  doubting 
which  are  stated  in  another  place  (page  69). 

65 


66  SYPHILITIC   INHERITANCE 

elapses.  The  abortions  precede  the  stillbirths,  the  stillbirths 
the  syphilitic  children,  the  syphilitic  children  the  healthy  ones. 
But  this  sequence  is  never  absolute.  It  may  be  brief  (consist- 
ing of  but  one  or  two  miscarriages  or  one  or  two  syphilitic 
children  and  nothing  more,  though  the  mother  remains  un- 
treated) :  it  may  be  indefinitely  prolonged.  It  usually  lasts 
from  four  to  six  years;  but  during  this  time  abortions,  syphi- 
litic children,  and  healthy  children  alternate  in  a  most  confus- 
ing succession.  It  is  even  possible  for  one  of  twins  to  be 
healthy,  the  other  infected. 

This  confusion  in  heredity  resembles  and  doubtless  reflects 
the  alternation  of  storm  and  calm  in  the  mother's  disease.  Just 
as  the  first  eruptions  are  likely  to  be  the  most  infectious,  so 
are  the  first  children  likely  to  be  the  most  infected.  But 
periods  of  calm  may  intervene  between  infected  children,  just 
as  between  infectious  lesions.  It  is  to  be  noted,  however,  that 
periods  of  calm  in  the  mother's  disease  may  coincide  with  the 
production  of  syphilitic  children ;  though  the  mother's  disease 
may  appear  absolutely  latent,  the  child  may  be — and  often  is — 
none  the  less  virulently  infected. 

4.  If  well  treated,  the  mother  ceases  to  bear  syphilitic  chil- 
dren during  the  administration  of  treatment;  but  she  may 
resume  her  tendency  to  bear  infected  children  after  the  cessa- 
tion of  treatment,  just  as  she  may  resume  the  tendency  to  show 
evidences  of  the  disease.     ■ 

5.  But  if  well  treated  in  the  first  three  years,  the  chances 
of  her  bearing  syphilitic  children  thereafter  are  slight. 

Let  me  illustrate  these  general  rules  with  a  tabulation  of 
cases  observed  by  my  father  and  myself. 

Among  43  women  innocently  infected  with  syphilis  in 
matrimony,  and  who  bore  children  after  said  infection,  only 
2 — think  of  it!  only  2 — escaped  bearing  at  least  one  syphi- 
litic child ;  and  this  exception  is  fully  compensated  for  by  3 
who,  before  realizing  they  had  the  disease  themselves,  infected 


SYPHILIS   AND    MATERNITY  "67 

a  child  whom   they  had  previously   brought  into  the  world 
healthy. 

Of  the  infecting  41 

23  bore  I  syphilitic  child  (or  fetus),  of  whom  5  bore  healthy  children  later. 
8  bore  2  syphilitic  children,  of  whom  6  bore  healthy  children. 
4  bore  3  syphilitic  children,  of  whom  2  bore  healthy  children. 

2  bore  4  syphilitic  children,  of  whom  2  bore  healthy  children. 

3  bore  5  syphilitic  children,  and  no  others. 

I  bore  8  syphilitic  children,  and  6  healthy  ones. 
Total,  41  bore  86. 

The  last  was  the  poorest  and  most  ignorant  of  the  lot :  she 
should  really  be  classed  as  a  hospital  case. 

Doubtless,  many  more  of  those  who  bore  but  one  syphilitic 
child  bore  healthy  children  after  they  had  passed  from  our 
treatment  and  observation,  just  as  many  of  their  sisters  who 
acquired  syphilis  without  a  husband  have  gone  through  their 
treatment  at  our  hands,  and  then  married  and  borne  perfectly 
healthy  children. 

Why  this  difference?  Why  does  the  unmarried  syphilitic 
woman  so  commonly  become  competent  to  bear  healthy  chil- 
dren while  syphilis  of  the  wedded  victim  almost  invariably  im- 
pairs the  health  or  destroys  the  life  of  at  least  one  child? 

The  difference  lies  in  knowledge  and  the  lapse  of  time.  The 
innocent  wife  does  not  realize  she  is  diseased  until  she 
brings  into  the  world  her  first  syphilitic  child  :  does  not  perhaps 
realize  it  even  then — witness  the  frequency  of  multiple  syphi- 
litic heredity — but  the  womaii  forewarned  and  forearmed  is  in 
little  danger.  Our  statistics  enforce  this  point :  In  37  cases  the 
interval  between  infection  of  the  mother  and  the  birth  of  the 
first  syphilitic  child  (or  fetus)  is  known;  in  32  it  was  a  year 
or  less,  thrice  between  one  and  two  years,  and  twice  at  two  and 
a  half  years.  On  the  other  hand,  the  interval  before  the  birth 
of  a  healthy  child  was  twice  two  years,  ten  times  three  years, 
twice  five  years,  once  seven  years,  and  once  ten  years. 


68 


SYPHILITIC    INHERITANCE 


Moreover,  the  duration  of  the  mother's  disease  at  the 
birth  of  the  last  syphilitic  child  (as  far  as  known)  is  shown 
to  fall  rapidly  by  the  figures  in  Column  IV.  of  the  table 
(below). 

Let  us  compare  the  infectiousness  of  syphilis  between  hus- 
band and  wife  and  between  mother  and  (unborn)  child  in  the 
following  table,  of  which  Column  I  (duration  of  matrimony 
before  infection  of  wife)  compared  with  Column  II  (duration 
of  mother's  disease  at  time  of  birth  of  first  syphilitic  fetus) 
shows  the  instant  infectiousness  of  syphilis;  Column  III  (dura- 
tion of  disease  in  husband  at  the  time  he  married  and  infected 
his  wife)  compared  with  Column  IV  (duration  of  disease  in 
mother  at  time  of  birth  of  last  syphilitic  fetus)  shows  the  great 
decrease  of  infectiousness  in  the  third  year  and  its  more  grad- 
ual disappearance  thereafter;  Column  V  (duration  of  syphilis 
in  man  before  marriage  to  wife  whom  he  did  not  infect)  com- 
pared with  Column  VI  (duration  of  disease  in  mother  before 
birth  of  first  uninfected  child)  shows  the  opposite  side  of  the 
picture,  the  sharp  rise  of  non-infection  in  the  third  year. 


Year                        I                II 

III 

IV 

V              VI 

I,  or  less 41              31 

2 I                3 

3 0       !         2 

4-5 .'         0       '         ° 

6-10 0               0 

11-13 0               0 

25 
10 

4 
3 
I 
0 

16 

9 
6 
6 

J. 

2 

2 

4 
16 

(0 

0 

2 
10 

(0 
(0 
C) 

It  seems  a  fair  inference,  therefore,  that  the  probability  of 
syphilitic  heredity,  like  the  probability  of  contact  infection  (in 
matrimony)  is  overwhelming  in  the  first  year  of  the  disease, 
great  in  the  second  and  third  years,  slight  in  the  fourth  and 
fifth  years,  and  negligible  thereafter.  But,  as  might  be  expected, 
from  the  more  intimate  contact  between  mother  and  unborn 

1  Returns  in  these  later  years  too  few  and  scattering  to  be  conclusive. 


THE   THEORY   OF    SYPHILITIC    HEREDITY  69 

child,  the  danger  of  syphiHtic  inheritance  persists  somewhat 
longer  than  the  danger  of  contact  infection. 


THE   THEORY   OF   SYPHILITIC    HEREDITY 

It  would  require  many  pages  to  elaborate  the  arguments 
employed  and  the  instances  adduced  by  every  author  who  has 
discussed  the  theory  of  syphilitic  heredity  to  prove  that  this 
disease  may  be  inherited  from  the  father  alone,  the  mother  re- 
maining uninfected.^  The  opposite  view,  i.  e.,  that  every  syph- 
ilitic child  has  a  syphilitic  mother,  has  practically  no  defenders 
except  Sturgis  ^  and  Matzenauer.^ 

The  facts  of  the  case  are  these:  the  child  (fetus)  may  con- 
ceivably be  infected  with  syphilis  in  one  of  five  ways : 

1.  At  the  moment  of  conception  by  the  father's  semen 
(paternal  heredity). 

2.  At  the  moment  of  conception  by  the  mother's  ovum 
(maternal  conception  heredity). 

3.  By  means  of  the  placental  circulation  to  the  healthy 
fetus    (maternal  post-conceptional'  heredity). 

4.  To  the  child  at  birth  from  lesions  of  the  mother's  geni- 
tals (infection  in  parturition). 

5.  To  the  infant  after  birth  either  from  its  parents  (e.  g., 
by  a  kiss  or  in  suckling),  or  from  an  indifferent  person  (e.  g., 
a  wet-nurse). 

In  these  two  latter  instances  (4  and  5)  the  disease  in  the 
infant  is  acquired  syphilis,  differing  from  hereditary  syphilis 
in  the  presence  of  a  chancre  at  the  point  of  inoculation,  and 
the  absence  of  the  grave  visceral  lesions  of  fetal  syphilis. 

'  Rosinski  (  "Die  Syphilis  in  der  Schwangerschaft")  offers  the  latest  con- 
tribution to  this  side  of  the  argument. 

2  Morrow's  "  System." 

^  Archiv  j.  Derniat.  u.  Syph.,  1903;  Wien.  med.  Presse,  1903,  vol.  xliv,  pp. 
284,  657,  805,  contains  a  debate  on  this  subject  between  Finger  and  Matzenauer. 


70  SYPHILITIC    INHERITANCE 

Paternal  Heredity. — Given  a  man  with  infected  semen,  it 
is  probable  that  he  will  infect  both  wife  and  child,  but  conceiv- 
able that  he  may  infect  either  without  the  other.  Actual  ex- 
amples of  such  exception  occasionally  appear.  Thus  an  un- 
treated, actively  syphilitic  mother  has  been  known  to  bear  an 
apparently  healthy  child,  though  such  an  occurrence  is  to  the- 
last  degree  exceptional  (page  69).  But  that  a  syphilitic  child 
should  issue  from  an  apparently  healthy  mother,  though  un- 
usual, is  by  no  means  rare.  (It  occurs  in  about  fifteen  per  cent 
of  cases.) 

This  purely  paternal  inheritance  has  been  and  is  almost 
universally  attributed  by  syphilographers  to  infection  of  the 
fetus  from  the  father's  semen,  the  mother  escaping  infection 
from  fetus  as  well  as  from  semen.  But  pathologists  have 
always  maintained  at  least  an  attitude  of  doubt  concerning  this 
unique  seminal  transmission  which  is  not  even  alleged  for  any 
disease  except  syphilis.  Let  us,  therefore,  array  the  evidence 
upon  each  side. 

In  favor  of  paternal  heredity  is  alleged  the  obvious  fact  that 
father  and  child  are  certainly  syphilitic,  the  mother  apparently 
sound. 

Against  it  is  urged  that  the  mother  is  not  absolutely  sound ; 
and  this  is  exhibited  in  various  ways.  In  the  first  place,  she  is 
subject  to  Colles's  law,  i.  e.,  the  apparently  healthy  mother  of 
a  syphilitic  child  cannot  be  infected  by  that  child,  whether  in 
nursing  it  or  by  any  accidental  contact;  the  child  may  infect 
any  non-syphilitic  person  except  its  own  mother. 

This  immunity  to  syphilis  exhibited  by  the  mother  of  a 
syphilitic  child  means  that  she  is  in  some  sense  syphilitic.  But 
in  what  sense?  Either  she  has  absorbed  from  the  fetus  some 
immunizing  substance  (or  developed  this  herself  in  the  excre- 
tion of  the  syphilitic  products  of  the  fetus),  or,  on  the  other 
hand,  she  is  actually  syphilitic.  In  favor  of  the  former  theory 
are: 


THE    THEORY    OF    SYPHILITIC    HEREDITY  71 

1.  Certain  reported  exceptions  to  Colles's  law,  the  mother 
developing  chancre  of  the  nipple  and  a  general  syphilis  after 
nursing  her  infant,^  and 

2.  The  repeated  insistence  of  almost  innumerable  observers 
that  in  such  instances  further  syphilitic  pregnancies  may  be 
prevented  by  antisyphilitic  treatment  of  the  father  alone.  The 
cases  cited  in  illustration  are  as  numerous  and  straightforward 
as  the  instances  of  exception  to  Colles's  law  are  few  and  ob- 
scure. 

Against  it  are : 

1.  Our  inability  to  evoke  a  similar  experimental  immunity 
in  man  or  monkey. 

2.  The  fact  that  some  nine  per  cent  of  syphilitic  women 
do  not  have,  or  at  least  do  not  remember  having,  any  early 
symptoms  of  the  disease  (page  78). 

3.  The  frequency  of  choc  en  retoitr,^  i.  e.,  the  appearance 
in  later  years  of  tertiary  syphilitic  lesions  upon  these  appar- 
ently clean  mothers.  In  such  instances  at  least  we  may  fairly 
say  that  the  mother  was  syphilitic,  but  skipped  her  early  symp- 
toms; and 

4.  The  decreasing  nocivity  of  hereditary  syphilis.  It  is 
well  known  that  whether  the  syphilis  in  the  parent  be  paternal 
or  maternal,  there  is  a  distinct  though  irregular  tendency 
toward  lessened  gravity  of  heredity  syphilis  in  successive  preg- 
nancies. Thus  in  a  typical  untreated  case  two  or  three  miscar- 
riages of  macerated  syphilitic  fetuses  are  followed  by  or  inter- 
mingled with  children  stillborn  at  term  or  born  so  gravely  in- 
fected as  to  die  within  the  first  few  weeks  of  extra-uterine  life. 

1  So  obscure  are  these  alleged  exceptions  that  Matzenauer  rejects  them 
all;  Finger  clings  to  a  few;  and  Hochsinger  believes  them  so  frequent 
as  to  prohibit  the  apparently  healthy  mother  from  nursing  her  syphilitic 
infant! 

'  This  term  represents  the  theory  that  in  these  cases  the  fetus  is  infected 
by  the  father,  the  mother  by  the  fetus;  a  distinction  that  seems  to  me  both 
futile  and  unnecessary. 


72  SYPHILITIC   INHERITANCE 

Then  follow  children  less  gravely  infected,  and  finally  the  taint 
is  eliminated  and  healthy  children  are  born.  When  the  syphi- 
lis is  purely  paternal,  the  sequence,  though  often  briefer,  is 
otherwise  similar  to  that  of  maternal  heredity. 

Now  this  decreasing  intensity  of  infection  is  commonly 
attributed  to  the  decreasing  virulence  of  the  father's  syphilis, 
although  syphilis,  like  any  other  contagious  disease,  is  entirely 
uninfluenced  in  its  severity  by  the  source  from  which  it  is  ac- 
quired, and  is  grave  or  mild  solely  according  to  the  susceptibil- 
ity of  the  individual  in  whom  it  exists. 

But  the  one  thing  most  likely  to  affect  the  vitality  of  the 
fetus  and  its  susceptibility  to  disease  is  the  condition  of  the 
placenta;  and  Matzenauer  has  attempted  to  show  that  the  de- 
creasing virulence  of  syphilis  in  successive  children  goes  hand 
in  hand  with  decreasing  syphilitic  inflammation  of  the  pla- 
centa. Accordingly,  if  one  accepts  the  infection  only  from  the 
mother,  one  can  readily  understand  how  her  first  children  suc- 
cumb more  fully  to  the  disease  because  of  the  more  intense 
lesions  in  the  placenta ;  while,  as  time  goes  on,  the  placenta, 
with  the  other  maternal  organs,  becomes  less  and  less  likely 
to  be  diseased.^ 

The  array  of  probabilities  against  a  purely  paternal  heredity 
— fortified  by  the  improbability  of  the  mother  escaping  so  viru- 
lent an  infection  in  the  fetus,  the  uniqueness  of  this  alleged 
syphilitic  seminal  heredity  and  the  impossibility  of  artificially 
producing  maternal  immunity — impresses  me  more  cogently, 
I  confess,  than  the  purely  clinical  observations  alleged  in  its 
favor.  That  paternal  heredity  is  less  frequent  than  would 
seem  is  surely  proven  by  the  frequency  of  choc  en  rctour;  ^ 
that  it  ever  occurs  I  do  not  know. 

1  The  more  prolonged  and  severe  infectiousness  of  an  obviously  maternal 
syphilis  is  even  more  readily  explicable  by  this  theory  than  by  the  other. 

2  The  discovery  (page  29)  of  spirochetiE  in  the  inguinal  glands  of  an  apparent- 
ly healthy  mother  simply  enforces  this  lessened  frequency,  as  does  the  case 


THE   THEORY   OF    SYPHILITIC   HEREDITY  73 

Maternal  Conceptional  Heredity. — Although  from  three 
fourths  to  four  fifths  of  syphiHtic  heredity  is  directly  traceable 
to  syphilis  of  the  mother,  and  although  in  most  instances  the 
mother  is  known  to  be  syphilitic  at  the  time  of  impregnation, 
it  is  difficult  if  not  impossible  to  assure  oneself  whether  the 
infection  reaches  the  fetus  through  the  ovum  (conceptional), 
or  through  the  placental  circulation  (post-conceptional).  The 
objection  of  decreasing  hereditary  virulence  urged  in  the  pre- 
ceding paragraphs  against  paternal  (conceptional)  heredity 
applies  with  almost  equal  force  against  maternal  conceptional 
heredity.  For  if  the  fetus  is  infected  from  the  ovum,  it  is  dif- 
ficult to  understand  why  the  second  or  third  or  fourth  ovum 
should,  if  infected  at  all,  be  any  less  virulently  infected  than  the 
first.  Whereas  a  decreasing  intensity  of  placental  inflamma- 
tion permits  better  and  better  nourishment  of  the  fetus  and  by 
so  much  retards  its  disease.  For  all  syphilitic  fetuses,  there- 
fore, except  those  aborted  in  the  first  few  months,  one  may 
doubt  a  conceptional  heredity. 

Maternal  Post-Conceptional  Heredity. — A  fetus  may  be 
infected  with  a  syphilis  acquired  by  the  mother  during  the 
first  seven  months  of  gestation.  It  is  extremely  doubtful 
whether  a  mother  infected  after  the  seventh  month  can  transmit 
the  disease  to  the  fetus  in  ntcro,  inasmuch  as  the  disease  would 
scarcely  have  time  to  be  generalized  in  her  (at  any  rate  there 
are  no  conclusive  cases  in  proof  one  way  or  the  other).  Such 
infection  is  the  rarest  form  of  hereditary  syphilis  as  far  as 
clinical  records  go ;  for  the  instances  of  fetal  infection  from 
which  conceptional  transmission  (antecedent  syphilis)  both 
paternal  and  maternal  can  be  excluded,  are  rare  indeed.  Yet 
following  out  the  line  of  argument  suggested  above,  it  seems 
highly  probable  (though  by  no  means  absolutely  proven)  that 

(related  to  me)  of  an  apparently  healthy  woman  continuing  to  bear  syphilitic 
children  to  a  second  (healthy)  husband  after  the  death  of  the  first  (syphilitic) 


74  SYPHILITIC    INHERITANCE 

maternal  post-conceptional  heredity  is  almost  (if  not  alto- 
gether) the  sole  type  of  syphilitic  heredity.  The  theories  of 
conceptional  heredity  are  founded  upon  evidence  so  exclusively 
clinical/  and  are  opposed  so  absolutely  by  our  experience  with 
every  other  disease  that  they  merit  at  best  a  guarded  and  con- 
ditional acceptance. 

Such  is  the  etiology  of  hereditary  syphilis  as  far  as  we 
know  it. 

Acquired  Syphilis  in  Infancy. — No  age  is  immune  to  syphi- 
lis. There  does  not  seem  to  be  even  a  relative  immunity  to  the 
disease  during  infancy  as  there  is  to  so  many  of  the  acute 
exanthemata.  But  it  has  been  alleged,  and  was  for  a  time  gen- 
erally believed,  that  the  non-syphilitic  child  of  a  syphilitic 
mother  could  not  (during  infancy,  at  least)  be  infected  with 
syphilis  by  that  mother  (or  by  anyone  else).  This  rule,  known 
as  Prof  eta's  lazv,  has  helped,  by  its  mystery,  to  illustrate  and 
to  obscure  the  interpretation  of  Colles's  law.  But  Profeta's 
law  is  so  full  of  exceptions  that  the  syphilographer  of  to-day 
adheres  to  it  in  little  more  than  this  sense — that  if  the  child 
has  escaped  intra-uterine  infection  it  may  well  hope  to  escape 
the  lesser  dangers  of  extra-uterine  infection. 

The  alleged  cases  of  infection  during  parturition  are  rare 
and  doubtful.  But  during  infancy  the  healthy  child  of  syphi- 
litic parents  may,  doubtless,  be  infected  quite  as  readily  as 
another.  Apparent  exceptions  (examples  of  Profeta's  law) 
are  due  either  to  the  relatively  slight  infectiousness  of  the  dis- 
ease (page  59)  or  to  the  fact  that  the  infant  is  already 
infected  with    (occult)    hereditary  syphilis. 

1  And,  one  might  add,  so  prejudiced — for  since  Kassowitz  opened  the  study 
of  this  subject  in  1876,  with  his  masterly  thesis  in  favor  of  paternal  heredity, 
it  has  never  been  thoroughly  discussed  from  the  opposite  point  of  view  until 
Matzenauer's  recent  publication. 


HEREDITARY  SYPHILIS  OF  THE  THIRD   GENERATION     75 

HEREDITARY    SYPHILIS    OF    THE    THIRD    GENERATION 

Inasmuch  as  a  man's  capacity  to  transmit  syphilis  to  his 
wife  almost  always  ceases  within  five  years  and  a  woman's 
capacity  to  bear  syphilitic  children  within  ten,  it  would  seem 
to  the  last  degree  improbable  that  a  child  born  syphilitic  should 
retain  the  power  of  transmitting  the  disease  until  it  reaches 
maturity.  Yet  such  is  the  postulate  of  those  who  maintain 
that  the  hereditary  syphilitic  may  in  turn  transmit  the  disease 
to  his  descendants.  Improbable  as  such  inheritance  may  seem, 
hereditary  syphilis  in  the  third  generation  (syphilis  twice  in- 
herited) is  accepted  and  instanced  by  a  formidable  array  of 
authorities.  Hutchinson  denies  it/  Taylor  ^  and  E.  Fournier  ^ 
accept  it  without  reserve.  Tarnowski,^  Barthelemy/  Jullien,'* 
and  Finger  ^  are  inclined  to  believe  in  it,  or  believe  at  least 
that  some  of  the  stigmata  are  transmissible  to  the  third 
generation. 

E.  Fournier  has  formulated  the  following  scheme  of  requi- 
sites to  the  proof  of  a  case : 

I.  The  grandchild  must — 

1.  Show  an  unmistakably  syphilitic  lesion  or  a  dystrophy 
that  can  be  fairly  (legitimement)  attributed  to  a  syphilitic 
taint. 

2.  Be  free  from  suspicion  of  acquired  syphilis. 
II.   The  parents  of  the  grandchild — 

3.  One  of  the  two  must  be  indubitably  affected  with  hered- 
itary syphilis. 

4.  This  parent  must  be  free  from  suspicion  of  a  super- 
added acquired  syphilis. 

'  Med.  Press  and  Circular,  1906,  August  i. 

^  Med.  Record,  1906,  vol.  Ixix. 

^  "Heredo-syphilis  de  seconde  generation,"  Paris,  1905. 

*  "Thirteenth  International  Congress,"  Paris,  1900. 

^  "Twelfth  International  Congress,"  Moscow,  1897. 

"  Wien.  klin.  Wochenschr.,  1900. 


76  SYPHILITIC    INHERITANCE 

5.  The  other  parent  must  be  free  from  suspicion  of  ac- 
quired syphiHs. 

III.  Finally,  of  the  grandparents — 

6.  At  least  one  of  them  must  be  proven  to  have  had  ac- 
quired syphilis. 

It  is  questionable  M^hether  a  chain  of  evidence  so  long,  so 
purely  clinical,  can  be  accepted.  So  much  depends  upon  the 
point  of  view  of  the  reporter ;  so  impossible  is  it  for  anyone  to 
prove  the  capital  conditions,  4  and  5. 

Indeed,  the  conclusions  of  those  who  accept  syphilis  of  the 
third  generation  illustrate  by  their  diversity  the  frailty  of  the 
evidence.  Thus  Tarnowski  says  (referring  to  endemic  syphi- 
Hs) : 

"  Parents  showing  symptoms  of  hereditary  syphilis  ...  do 
not  transmit  syphilis  to  their  children  as  a  hereditary  disease 
{sous  la  forme  hereditaire) . 

"  The  dystrophies  ^  of  the  second  syphilitic  generation  are 
not  always  transmitted  to  the  third  generation  as  identically  the 
same  dystrophies. 

"  Children  of  syphilitic  parents  inherit  a  certain  immunity  to 
syphilis  (Prof eta's  law^);  but  this  hereditary  immunity  is  but 
temporary;  generally  (with  rare  exceptions)  it  ceases  at  infancy 
or  at  the  age  of  puberty. 

"  At  this  age  the  individual,  though  born  of  syphilitic  parents, 
becomes  vulnerable  to  syphilis.  This  new  infection  I  call  syphilis 
binaria.  I  have  frequently  observed  it,  especially  in  rural  (en- 
demic) syphilis. 

"  Hereditary  syphilis  in  the  third  generation  is  generally  due 
to  syphilis  hinaria. 

"  The  third  generation  may  also  show  symptoms  of  hereditary 
syphilis,  in  case  (though  this  is  relatively  unusual)  a  person  with 
hereditary  syphilis  marries  one  with  acquired  syphilis." 

» Cf.  page  532. 

2  These  children  are  presumed  to  be  syphilitic.  Hence  Tarnowski's  inter- 
pretation of  Profeta's  law  is  simply  the  assertion  that,  so  long  as  an  individual 
is  syphilitic,  he  cannot  catch  the  disease  again. 


HEREDITARY   SYPHILIS   OF   THE   THIRD   GENERATION     77 

In  contrast  with  the  imphed  frequency  of  this  inheritance 
in  Tarnowski's  eyes  we  may  place  the  experience  of  Bar- 
thelemy  and  Taylor  who,  though  firm  believers  in  the  theory 
and  favored  with  an  immense  clinical  experience  (and  not  lean- 
ing upon  the  ingenious  theory  of  sypJiilis  binaria)  have  re- 
ported respectively  only  five  and  two  cases.  Finally,  E.  Four- 
nier  denies  the  tJieory  of  syphilis  binaria,  while  admitting  the 
fact,  reports  in  detail  116  cases  (of  w^hich  6  are  his  own  and  6 
his  father's — from  among  the  tens  of  thousands  of  syphilitics 
seen  by  Professor  Fournier),  and  concludes  that: 

"  I.  Hereditary  syphilis  of  the  third  generation  (syph.  hered, 
dc  2de  generation)  exists. 

"  2.  It  is  rarely  noted  clinically  because  of  the  impediments 
to  its  recognition. 

"  3.  The  mortality  in  this  generation  is  such  as  to  kill  two 
fifths  of  its  members. 

"  4.  It  usually  shows  itself — in  four  fifths  of  the  cases  accord- 
ing to  my  observations — by  dystrophic  stigmata  similar  in  every 
way  to  those  of  hereditary  syphilis   (heredite  prime). 

"  5.  It  sometimes  exhibits  symptoms  of  syphilis  (symptomes 
virulents) ,  but  far  less  frequently — fourteen  per  cent,  according 
to  my  observations." 

In  face  of  such  a  general  agreement  as  to  principles,  and 
in  spite  of  the  divergent  interpretation  of  details,  one  must  at 
least  confess  that  hereditary  syphilis  in  the  third  generation 
is  possible,  though  it  must  be  eminently  rare.  And  one  may 
add  by  w^ay  of  precaution  that  the  other  factors  in  heredity 
— especially  in  the  production  of  congenital  dystrophies — 
such  as  alcohol,  privation,  etc.,  whose  influence  is  so  marked 
upon  syphilis  in  the  first  and  second  generation,  must  be  im- 
portant elements,  and  are  perhaps'  even  the  important  elements 
in  determining  syphilitic  heredity — especially  dystrophic  hered- 
ity— in  the  third  generation. 


CHAPTER    VII 
THE  COURSE  OF  SYPHILIS 

THE   ONSET 

Although  utterly  irregular  in  its  course,  syphilis  is  prac- 
tically always  quite  characteristic  in  its  beginnings  (at  least 
in  the  male),  and  thus  the  diagnosis  of  syphilis  is  happily 
most  readily  made  at  the  time  when  it  is  most  necessary  to 
make  it. 

Onset  in  Man. — In  order  to  get  a  picture  of  the  way  in 
which  syphilis  begins  let  us  take,  for  example,  a  typical  case 
in  a  man.  He  has  intercourse  on  a  given  date  (and  may 
notice  an  abrasion  upon  the  penis,  or  there  may  come  out 
within  the  next  few  days  a  crop  of  herpetic  vesicles.  Yet,  in 
the  great  majority  of  instances  neither  of  these  things  is 
noted).  He  thinks  himself  entirely  normal  and  notices  noth- 
ing wrong  for  a  period  of  three  to  five  weeks.  Then  he  acci- 
dentally becomes  aware  that  there  is  upon  the  glans  penis 
or  upon  the  foreskin  a  single  pimple.  This  grows  and  be- 
comes quite  hard,  and  is  eroded  or  ulcerated  upon  its  surface. 
In  a  week  or  ten  days  the  glands  in  one  or  both  groins  begin 
to  swell,  yet  the  sore  itself  and  the  glands  are  practically  pain- 
less, and,  as  neither  of  them  attains  any  great  size,  the  patient 
may  neglect  to  consult  a  physician.  But,  though  relatively 
insignificant,  the  sore  does  not  get  well ;  the  glands  do  not  dis- 
appear. Three  or  four  weeks  go  by  and  the  ulceration  upon 
the  surface  of  the  sore  gradually  heals,  but  a  hard,  typical  lump 
remains  under  the  epidermis.  Then,  in  from  two  to  three 
78 


THE    ONSET 


79 


months  from  the  time  of  infection,  the  first  general  symptoms 
appear. 

First,  he  begins  to  feel  a  little  miserable;  his  bones  ache; 
he  feels  perhaps  a  little  feverish,  but  probably  not  definitely 
sick,  and  may  take  no  very  great  account  of  his  malady  until 
he  notices  a  rash  upon  his  body  or  some  sore  spots  in  the 
mouth  or  pharynx.  These  are  pretty  sure  to  bring  him  to  the 
physician,  who  finds  him  with  a  characteristic  macular,  papu- 
lar, or  polymorphous  eruption  (to  be  described  in  detail  later), 
with  little  sores  in  the  mouth  or  pharynx,  with  disseminated, 
minute,  scabbed  ulcerations  in  the  scalp,  perhaps  with  a  slight 
evening  rise  of  temperature,  and  tender  sternum  and  shins. 
He  is  in  full  secondary  syphilis.  The  diagnosis  is  unmistak- 
able. 

Onset  in  Woman. — Such  is  the  course  followed  by  almost 
all  men.  In  women  the  onset  of  the  disease  is  by  no  means  so 
characteristic.  The  chancre  is  so  slight  a  lesion  that  it  may 
very  well  be  overlooked  by  the  patient,  and  she  may  fancy  her- 
self entirely  well  until,  two  or  three  months  after  infection, 
she  begins  to  feel  run  down.  She  may  have  enough  fever  to 
fancy  she  has  malaria,  or  she  may  be  treated  for  an  imaginary 
typhoid ;  or  she  may  suffer  from  frightful  pains  in  her  bones, 
in  her  head,  these  pains  coming  on  in  the  evening  and  much 
worse  at  night  than  during  the  day.  A  short  while  after  the 
beginning  of  this  outbreak  of  general  toxemia  she  may  show 
lesions  of  skin  and  mucous  membrane  quite  as  characteristic 
as  those  found  in  the  male.  But  in  a  certain  proportion  of 
cases  (page  45)  these  objective  evidences  are  so  faint  as  to  be 
overlooked  and,  consequently,  she  does  not  present  a  typical 
and  unmistakable  picture  of  the  disease.  In  such  cases  re- 
peated miscarriages,  or  the  birth  of  children  that  promptly  die, 
may  constitute  the  only  early  symptoms. 

If  the  diagnosis  is  not  made,  her  symptoms  may  gradually 
abate,  and  it  may  be  years  before-  a  tertiary  outbreak  proves 


8o     •  THE    COURSE    OF    SYPHILIS 

that  she  has  syphihs.     Or  she  may  go  on  to  have  some  char- 
acteristic lesion  within  a  few  weeks  or  months. 


DURATION  OF  PRIMARY  AND   SECONDARY  INCUBATION 

Such  is  the  beginning  of  syphihs  as  w^e  see  it  cHnically. 
It  may  be  divided  into  two  periods :  the  primary  incubation, 
ending  with  the  appearance  of  the  primary  lesion — the  chancre 
— and  the  secondary  incubation,  ending  with  the  appearance 
of  the  secondary  lesions. 

But  this  beginning  is  subject  to  certain  variations,  the 
clinical  extent  of  which  may  be  exemplified  by  the  following 
statistics. 

Lang  has  collected  45  cases  of  experimental  inoculation 
with  syphilis,  in  36  of  which  the  duration  of  the  primary  incu- 
bation was  noted,  in  37  that  of  the  secondary  incubation,  and 
in  29  that  of  the  total  incubation — the  time  between  inoculation 
and  the  advent  of  secondary  symptoms.  But  such  cases, 
though  scientifically  accurate,  do  not  present  the  facts  as  we 
meet  them  in  practice. 

Clinically,  we  depend  for  the  discovery  of  the  chancre  and 
even  of  the  secondary  symptoms,  not  upon  the  alert  and  trained 
specialist,  but  upon  the  casual  and  unskilled  patient  who  may, 
and  often  does,  overlook  the  most  characteristic  evidence  of 
his  disease. 

In  order,  therefore,  to  contrast  the  scientific  fact  and  its 
clinical  semblance.  I  have  studied  a  number  of  cases  in  which 
the  various  incubations  are  recorded  clinically  and  place  the 
two  tables  side  by  side. 


DURATION  OF  PRIMARY  AND  SECONDARY  INCUBATION    8l 


PRIMARY  INCUBATION 

SECONDARY  INCUBATION' 

Experi- 
mentally 

Clinically 

I 
I 
3 

7 

I 

34 

52       1 

67       i 
21 

I 

5 
2 

I 

Experi- 
mentally 

Clinically 

<  days 

I  week 

I 

7    " 

2  weeks 

2 

7 

9 

105 

123 

68 

10 

43 

13 

3 

3 

8    " 

^      "      -  -  - 

lO    " 

I 

4  to  5  weeks 

6  to  7       "   

8  to  9       "   

10  to  II       "    

12  to  13      "    

4  months 

5  "       

6  " 

s 

8 

5 
8 

4 
4 

I 

II    " 

2  weeks 

3  "      

4  to  5  weeks 

6  weeks 

7  " 

8 
12 

14 

I 

8  to  9  weeks 

lo  weeks 

7        " 

82  days 

16        " 

Total 

Total.. 

36 

196 

37 

387 

TOTAL  INCUBATION 


Experi- 
mentally 


Clinically 


1  month., 
i^  months 

2  " 

2^      " 

3  " 
3h  " 

4  " 
4i  " 

5  " 
6 

17      " 
Total. 


29 


2 
21 
49 
30 
16 


139 


Comparison  of  the  two  tables  shows  the  primary  incubation 
to  vary  between  ten  days  and  six  weeks  actually  -  in  every 
case,  clinically  in  ninety-three  per  cent;  the  secondary  incuba- 

'  Cases  receiving  no  mercury  before  the  appearance  of  the  secondary  symp- 
toms; for  if  mercury  is  pushed  the  secondaries  may  be  postponed  or  altogether 
inhibited. 

^  At  least  as  far  as  the  collected  statistics  show. 


82  THE   COURSE   OF    SYPHILIS 

tion  within  five  months  actually  in  all,  clinically  in  98.7  per 
cent;  and  the  total  incubation  between  one  and  six  months 
actually  in  all,  clinically  in  ninety-nine  per  cent. 

These  we  may,  therefore,  accept  as  the  extreme  limits  of 
the  various  incubation  periods,  viz. : 

First  incubation  (inoculation  to  chancre)  =  ten  days  to  six 
weeks. 

Second  incubation  (appearance  of  chancre  to  secondaries) 
=  within  five  months. 

Total  incubation  (inoculation  to  secondaries)  =  one  month 
to  six  months. 

How  important  the  delimitation  of  these  periods  is  can  be 
appreciated  only  by  the  prudent  practitioner  who,  convinced 
of  his  inability  to  make  an  infallible  diagnosis  from  the  chan- 
cre alone  must  wait  the  full  limit  of  time  before  declaring  his 
patient  free  from  syphilis  (page  243). 

But  if  the  patient  actually  has  syphilis,  it  is  rarely  neces- 
sary to  wait  so  long,  for  clinically  the  secondary  incubation 
falls  within  three  months  in  ninety-four  per  cent,  and  the  total 
incubation  within  four  months  in  ninety-six  per  cent  of  all 
cases.  What  might  be  termed  "  the  normal  case  "  runs  a  pri- 
mary incubation  from  two  to  five  weeks,  a  secondary  incuba- 
tion from  one  to  three  months,  a  total  incubation  from  six 
weeks  to  four  months. 

The  chancre  itself,  though  usually  single,  may  be  multiple 
in  ten  per  cent  to  twenty-five  per  cent  of  cases  (page  224),  or 
extragenital  (page  54),  or  urethral  (page  235).  In  about 
five  per  cent  of  men  ^  the  chancre  is  never  found  and  in  a  far 
larger  proportion  of  women.  The  chancre  lasts  at  least  two 
weeks,  usually  six  weeks,  sometimes  longer. 


1  Twenty-four  out  of  549  cases.  In  many  instances  the  examining  physician 
wovild  undoubtedly,  have  found  the  chancre  had  he  possessed  the  skill  of  an 
expert. 


THE    SECONDARY   SYMPTOMS  83 

THE    SECONDARY   SYMPTOMS 

The  secondary  symptoms,  if  anticipated  by  treatment,  may 
never  appear.  Indeed,  the  early  symptoms,  both  primary  and 
secondary,  are  entirely  overlooked  ^  in  one  per  cent  of  men 
(22  out  of  2,170)  and  in  nine  per  cent  of  women  (18  out 
of  207). 

But  when  they  do  occur,  what  is  their  usual  type?  their 
order  of  occurrence?  their  intensity?  their  duration? 

Any  student  of  syphilis  can  answer  such  questions  vaguely, 
though  it  is  all  but  impossible,  so  various  are  the  influences 
concerned,  to  answer  them  accurately.  The  patient's  age  and 
social  condition,  his  constitution  (tuberculosis,  malaria)  and 
habits  (alcohol,  tobacco),  his  willingness  and  ability  to  take 
adequate  treatment,  and  above  all  else  the  physician's  intelli- 
gence in  admJnistering  treatment — how  estimate  the  results  of 
such  diverse  influences?  To  be  accurate  is  surely  impossible. 
Yet  it  seems  not  unprofitable  to  tabulate  for  what  they  may 
be  worth  the  clinical  facts  recorded  upon  the  office  cases  of 
which  I  have  a  record. 

Definition. — The  secondary  symptoms  of  syphilis  are  two- 
fold, an  acute  toxemia  and  certain  local  lesions  varying  in 
character  from  simple  congestion  to  exudation.  These  local 
lesions  are  not  destructive  in  character,  do  not  invade  the 
adjoining  tissues,  do  not  undergo  caseation,  and  on  healing 
leave  little  or  no  scar.  They  have  usually  a  spontaneous  tend- 
ency to  heal. 

Differentiation  between  Secondary  and  Tertiary  Lesions.— 
Although  the  local  lesions  of  syphilis  are  often  typically  sec- 
ondary or  typically  tertiary  in  type,  there  is  a  large  intermedi- 


» I  do  not  say  skipped.  In  only  one  man  do  I  know  that  careful  inspection 
failed  to  reveal  any  secondary  symptoms  following  the  chancre.  Such  cases  are 
occasionally  recorded  but  almost  invariably  develop  tertiary  lesions  in  later 
years. 


84  THE    COURSE    OF   SYPHILIS 

ate  class  that  taxes  the  keenest  diagnosis.  Many  a  skin  syph- 
ihd,  for  example,  may  begin  with  a  frankly  secondary  aspect 
only  to  degenerate  later  into  an.  equally  typical  tubercle  or 
ulcer. 

But  the  difficulty  in  classifying  syphilis  of  the  skin  which 
can  be  watched  and  studied  day  by  day  is  as  nothing  compared 
to  the  errors  constantly  committed  in  classifying  syphilis  of 
bone  and  syphilis  of  the  nervous  system,  for  these  we  know 
less  directly  and  judge  chiefly  by  their  effects.  The  distin- 
guishing features  of  these  various  lesions  need  not  be  dis- 
cussed here;  but,  be  it  borne  in  mind,  the  differentiation  be- 
tween secondary  and  tertiary  lesions  may  be  difficult  and  is 
sometimes  impossible. 

Secondary  Toxemia. —  Examination  of  the  blood  during 
the  first  few  months  of  syphilis,  or  at  least  until  the  disease 
is  controlled  by  treatment,  reveals  a  secondary  anemia,  the 
characteristics  of  which  are  described  elsewhere  (page  254). 
In  the  majority  of  cases  in  one's  private  practice  this  condition 
reveals  itself  but  by  one  symptom :  viz.,  loss  of  weight. 
Whether  the  patient's,  distress  and  worry  over  his  malady  is 
not  often  largely  responsible  for  this  is  an  open  question.  But 
whatever  the  exact  cause,  one  very  frequently  finds  the  syphi- 
litic ten,  twenty,  or  even  thirty  pounds  lig"hter  at  the  end  of  six 
months  than  he  was  the  day  of  his  infection.  This  loss  is 
gradually  regained  under  treatment. 

On  the  other  hand,  typical,  severe  syphilitic  toxemia  with 
fever,  prostration,  and  various  pains,  preceding  the  outbreak 
of  the  localized  secondary  symptoms,  is  so  rare  as  to  be  almost 
always  mistaken  for  malaria  or  typhoid  fever  until  the  erup- 
tive lesions  appear  and  establish  the  diagnosis,  unless,  as  hap- 
pened to  a  youth  who  came  to  me  in  the  full  glory  of  a  general 
papular  syphilid,  it  suggests  measles. 

The  long  drawn-out  debility,  with  loss  of  weight  as  its 
most  striking  symptom,  is  much  more  severe  among  women 


THE    SECONDARY   SYMPTOMS  85 

than  among  men.  The  acute,  preemptive  febrile  toxemia  I 
find  noted  only  31  times  among  826  men  and  thrice  among  86 
women;  about  3.5  per  cent. 

Local  Symptoms. — The  first  local  secondary  symptom  ap- 
pears on  the  skin  in  almost  every  case.  Thus,  among  826 
cases,  one  showed  no  secondary  symptoms,  772  (ninety-three 
per  cent)  began  with  skin  lesions,  the  remainder  with  lesions 
of  the  mucous  membranes. 

This  first  eruption  is  macular  or  maculopapular,  and  gen- 
erally distributed  over  the  trunk,  less  marked  on  the  extremi- 
ties (see  page  280).  Exceptionally,  it  is  preceded  by  a  few 
scattered  papules.^ 

The  Early  Secondary  Lesions. — But  soon  a  whole 
group  of  symptoms  appears  to  form  the  characteristic  picture 
of  early  syphilis.  The  body  is  covered  with  macules  or  pap- 
ules; the  scalp  is  full  of  moist  crustaceous  papules  ("scabs," 
the  patient  calls  them)  ;  there  are  pains  in  the  joints,  the  bones, 
the  muscles,  the  head;  the  mouth  and  throat  are  filled  with 
mucous  papules  and  erosions;  the  lymph  nodes,  especially  the 
epitrochlear  and  posterior  cervical,  become  enlarged,  while  the 
scar  of  the  chancre  with  its  satellite  adenitis  still  marks  the 
port  of  entry. 

Such  is  the  pathognomonic  picture  of  secondary  syphilis 
at  its  outset.  The  picture  lasts,  in  any  or  all  of  its  constitu- 
ents, from  a  week  or  two  to  a  month  or  two. 

The  following  list  shows  the  lesions  noted  at  this  time. 
The  occurrence  of  "  scabs  "  in  the  scalp  and  of  enlarged  lymph 
nodes  is  not  tabulated.  The  former  is  all  but  constant.  The 
latter  develop  within  the  first  six  months,  but  are  by  no  means 
always  found : 

1  In  five  cases,  four  men  and  one  woman,  the  first  skin  lesion  noticed  was 
psoriatic  in  type,  in  three  men  it  was  bulbous,  in  two  others  pustular,  in  one 
tubercular. 


86 


THE   COURSE    OF   SYPHILIS 


LESIONS    AT    ONSET    OF    SECONDARY    SYMPTOMS 


Lesions  of  skin  and  mouth  or  throat  (pains  slight  or  absent) . 

The  same  with  severe  pains 

Skin  lesions  alone .' 

Skin  lesions  and  severe  pains 

Skin  lesions  and  mucous  papules  about  the  genitals  or  anus 

Skin  ^    i    Lesions  of  the  mouth  or  throat 

lesions  <    Lesions  of  the  mouth  or  throat  and  pains 

absent    (   Lesions  of  the  mouth  or  throat  and  genitals 

Total 


Male 


825 


Female 


520 

16 

131 

16 

78 

10 

38 

II 

5 

0  I 

40 

3 

6 

2 

7 

5^ 

63 


The  Subsequent  Secondary  Lesions. — After  the  sub- 
sidence of  this  first  outbreak  the  occurrence  of  secondary  symp- 
toms follows  no  rule.  Lesions  of  the  skin  and  mucous  mem- 
branes are  likely  to  relapse,  but  at  what  intervals  one  cannot 
prophesy.  A  surprisingly  large  proportion  of  well-treated 
cases — perhaps  one  in  five — ha\'e  no  further  secondary  symp- 
toms. Relapses  are  most  frequent  in  the  first  year.  There- 
after in  a  well-treated  case  they  are  likely  to  be  few  and  far 
between.  That  there  is  any  period  to  the  relapse,  any  definite 
interval  of  three  months  or  six  months,  after  which  a  recrudes- 
cence of  symptoms  may  be  looked  for  (as  some  Continental 
authorities  allege),  I  do  not  believe. 

The  farther  we  go  from  the  beginning  of  the  disease  the 
longer  are  likely  to  be  the  intervals  between  outbreaks.  With 
the  lapse  of  time  the  symptoms  themselves  become  less  gen- 
eral, less  symmetrically  distributed,  less  evanescent,  less  super- 
ficial, less  infectious;  in  fact,  they  approach  more  and  more 
the  tertiary  type. 

The  following  list  shows  the  rarer  secondary  lesions  ob- 
served during  the  course  of  911  cases.     It  conveys  a  general 

» Modesty  has  surely  diminished  these  figures  as  much  as  cleanliness. 
2  In  some  of  these  cases  an  antecedent  skin  eruption  had  doubtless  escaped 
the  patient's  observation  and  vanished  leaving  no  trace. 


THE  SECONDARY  SYMPTOMS 


87 


notion  of  the  frequency  of  these  lesions  and  symptoms,  though 
by  no  means  exhausting  the  lesions  of  secondary  syphilis : 


OCCURRENCE    OF    THE    RARER    SECONDARY    LESIONS 


Onychia  and  Paronychia 

Headache  (severe) 

Periostitis  (marked) 

Iritis 

Deafness 

Pleurodynia 

Laryngitis 

Jaundice 

Tenosynovitis 

Epididymitis 

Nephritis 

Hydrarthrosis 

Choroiditis 

Opacity  of  the  vitreous . . 

Pigmentary  syphilid 

Hemorrhagic  syphiHd... 


Women 


Duration  of  the  Secondary  Symptoms. — Even  to  the 
present  day  physicians  continue  to  speak  of  secondary  and  ter- 
tiary periods  of  syphilis.  Despite  all  that  has  been  written  to 
discourage  such  a  classification  they  cling  to  the  theory  that 
the  secondary  lesions  of  syphilis  cease  to  recur  after  a  year  or 
two,  and  that  every  symptom  of  syphilis  thereafter  must  be 
tertiary.  No  belief  could  be  more  false  or  more  misleading. 
How  false  I  shall  show  in  a  moment,  how  misleading  we  may 
realize  when  we  consider  that  the  secondary  lesions  are  essen- 
tially curable  by  mercury  rather  than  by  iodides,  while  rarely 
a  late  secondary  lesion  may  be  infectious. 

Yet  we  daily  encounter  such  secondary  lesions  as  the 
squamous  palmar  syphilid  or  the  erosive  glazing  glossitis  late 
in  the  disease.  We  meet  them  constantly  as  late  as  five,  rarely 
as  late  as  ten,  years  after  the  chancre,  and  other  secondary 
lesions  may  rarely,  to  be  sure,  yet  most  indubitably  appear 


88  THE   COURSE   OF   SYPHILIS 

years  after  the  chancre,   years  after  the  last  tertiary  symp- 
tom even. 

It  would  take  a  volume  to  develop  this  subject  in  all  its 
detail.  Indeed,  Fournier  has  recently  consecrated  a  volume  to 
it/  from  which  I  borrow  confirmation  to  my  own  observations. 
First,  let  me  detail  a  few  striking  case  histories ;  then  a  statis- 
tical resume : 

Case  XII. — Relapses  of  squamous  syphilid  at  six  (  +  )  and 
twenty-five  (  +  )  years.  This  patient,  when  seen  by  Dr.  V^an 
Buren  on  January  15,  1869,  at  the  age  of  forty,  had  had  "true 
syphilis — chancre  and  spots  on  palms."  He  was  suffering  at  the 
time  from  "  pains  in  the  chest,  which  he  calls  rheumatism,  weak- 
ness and  slight  wasting  of  the  lower  limbs,  constipation,  and 
difficulty  of  bladder."  All  these  symptoms  had  begun  in  the 
spring  of  1868  with  two  attacks  of  acute  retention  of  urine.  He 
was  found  to  be  suffering  from  cystitis,  with  eight  ounces  of 
residual  urine,  atony  of  the  bowel,  and  weak  and  atrophied  leg 
muscles  from  "  inflammation  of  the  spine."  "  Syphilis  of  the 
cord  "  was  diagnosed.  Under  sounds,  regular  catheterism  with 
lavage,  and  mixed  treatment,  the  bladder  improved  for  a  time, 
but  soon  settled  into  chronic,  complete  retention,  in  which  it  has 
remained  ever  since.  With  advancing  years,  legs  and  bowel 
have  also  grown  weaker.  But  there  has  never  been  any  ataxic 
gait,  girdle  pains,  or  eye  symptoms.  The  patellar  reflexes  are 
gone.  In  short,  the  condition  appears  to  be  one  of  irregular 
syphilitic  spinal  sclerosis. 

The  only  other  symptoms  of  syphilis  observed  are  the  follow- 
ing: In  May,  1869,  "secondary  eruption  on  palms,  scrotum,  and 
tongue."  In  November,  1875,  "  small  nummular  patches  of  dry, 
livid  scales  (scaly  patches),"  cured  in  a  month  by  mixed  treat- 
ment and  arsenic,  then  relapsing  and  followed  by  "  large  general 
excoriations  on  inside  of  mouth,"  which  cleared  up  in  January, 
1876,  under  increase  of  iodid  and  continuance  of  arsenic. 

In  December,  1894,  "  squamous,  circinate  syphilid  on  the  sole 
of  the  right  foot,"  promptly  cured. 

He  took  mixed  treatment  for  about  one  year  in  1869,  over  a 


Syphilis  secondaire  tardive,"  1906. 


THE    SECONDARY   SYMPTOMS  89 

year  in  1875-76,  and  for  a  short  period  in  1894.  He  has  been 
constantly  under  observation  and  treatment  for  the  bladder  paral- 
ysis and  urinary  infection  therefrom  resulting  from  1869  to  1907, 
and  the  history  is  therefore  singularly  accurate,  except  in  that 
we  cannot  learn  how  long  before  1869  the  disease  began — gurely 
before  the  acute  retention  in  1868,  perhaps  several  years  before. 

Case  XIII. — Interval  of  over  fourteen  years;  frequent  short 
courses  of  treatment ;  secondary  syphilid  of  tongue  in  tzventy- 
third  year.  Female.  Contracted  syphilis  in  1883,  at  the  age  of 
twenty-three.  No  chancre  noted.  Early  skin  and  mouth  lesions 
and  treatment.  When  first  seen,  in  October,  1884,  about  a  year 
after  the  commencement  of  the  disease,  she  had  vulvar  condy- 
lomata. Treatment  was  continued,  and  in  October,  1885,  she 
had  a  squamous  palmar  syphilid.  In  May,  1886,  a  mucous  papule 
in  the  mouth.  In  July,  1888,  palmar  papules.  In  October,  1889, 
"  vulvar  lumps."  In  January,  1894,  "  rheumatism."  In  March, 
1899,  "  anemia."  In  February,  1900,  "  nervous  dyspepsia."  In 
April,  1903,  "  neuralgia  and  anemia."  In  April,  1905,  "  neu- 
ralgia," and  there  are  some  indefinite  erosions  on  the  tongue. 
In  April,  1906,  her  mother  has  died,  and  the  neuralgia  and  head- 
ache are  worse.  The  tongue  is  distinctly  syphilitic,  the  glossite 
depapillante  of  Fournier.     She  does  not  smoke. 

This  patient  was  constantly  under  treatment  for  the  first  two 
years  of  her  disease,  and  although  from  October,  1889,  to  April, 
1906,  she  showed  no  recognizable  symptoms  of  syphilis,  short 
courses  of  mixed  treatment,  together  with  other  remedies,  were 
administered  on  all  the  occasions  noted  above  in  order  to  calm 
her  fears.  A  more  continuously  treated  case  could  scarcely  be 
imagined. 

Case  XIV. — Relapse  of  papules  in  third  and  fourth  years. 
Occasional  treatment.  Pustular  syphilid  in  thirtieth  year. 
Chancre  in  1869  at  the  age  of  twenty-nine.  When  first  seen, 
three  years  later  (December,  1872),  the  left  pupil  was  contracted 
and  adherent  from  iritis  and  the  right  one  dilated.  On  buttocks 
and  shins  scars  of  syphilitic  ecthyma,  on  the  arms  a  symmetri- 
cal active  papular  syphilid.  On  the  scrotum,  chromophytosis. 
General  condition  poor.  Previous  treatment  not  noted.  He 
has  been  treated  for  paresis  on  account  of  some  emotional  dis- 
turbance. 


go  THE    COURSE   OF    SYPHILIS 

The  patient  was  put  on  a  tonic  and  mixed  treatment.  He 
gradually  gained  weight,  the  eruption  was  cured,  relapsed  in 
April,  1873,  and  in  January,  1874.  In  the  fall  of  1874  he  had 
gained  over  twenty  pounds,  and  was  well  but  for  a  persistent 
mydriasis  of  the  right  pupil.  Was  seen  again  in  1890,  1892,  1893, 
1894,  and  given  a  little  mixed  treatment  to  allay  various  fears. 

In  September,  1900,  he  presented  "  some  small  ecthyma  " ; 
was  given  mixed  treatment  again,  and  in  October  it  is  noted 
"  ecthymatous  spots  well ;  each  leaves  a  clean-cut,  smooth,  round, 
thin  scar,  and  was  clearly  a  specific  lesion."  Well  in  December, 
1902. 

Case  XV. — Relapsing  erosive  lesions  of  tongue  for  tzventy 
years.  Lip  chancre  in  1870,  at  the  age  of  twenty-one.  Glands 
under  jaw  enlarged ;  many  early  mouth  lesions.  No  skin  lesions 
remembered.     Early  treatment  probably  adequate. 

When  first  seen,  in  January,  1890,  he  reports  that  for  at  least 
ten  years  past  the  tongue  has  almost  constantly  troubled  him. 
Treatment  irregular.  Habits  as  to  alcohol  and  tobacco  not  stated. 
Examination  of  the  tongue  reveals  thin  scars  along  the  edges, 
with  here  and  there  active  superficial  erosions.  Under  mixed 
treatment  and  cauterization  with  silver  nitrate  the  tongue  heals 
in  a  month.  Treatment  continued  four  months.  Relapse  on 
tongue  eight  months  later,  in  January,  1891 ;  mixed  treatment 
three  months  thereafter.  No  further  relapse  when  last  seen,  in 
April,  1892. 

Case  XVI. — Relapse  of  squamous  syphilid  and  suppurative 
onychia  after  twenty--five  years.  Chancre  in  1871,  at  the  age  of 
twenty,  followed  by  slight  secondaries,  chiefly  buccal.  Drinks 
beer  heavily  and  does  not  smoke.  Has  taken  very  little  treat- 
ment. When  first  seen,  in  February,  1896,  he  shows  a  scarred 
and  fissured  tongue,  without  active  lesions  upon  it,  a  suppurative 
onychia  of  one  finger,  and  a  circinate  squamous  eruption  on  the 
palms  and  elsewhere.  He  remains  under  treatment  only  two 
months,  at  the  end  of  which  time  he  is  much  improved  by  mixed 
treatment  ("hands  clean")  and  the  cessation  of  alcohol.  Then 
he  takes  to  drinking  again,  and  disappears. 

Here  are  five  cases  showing  relapse  of  typical  secondary 
symptoms  from  twenty  to  thirty  years  after  the  occurrence  of 


THE   SECONDARY   SYMPTOMS  91 

chancre.  If  they  stood  alone,  unsupported  by  many  others  of 
less  and  a  few  of  equal  duration,  unconfirmed  by  the  reports 
of  other  observers,  they  might  all  be  put  down  to  honest  but 
mistaken  enthusiasm.  But  the  weight  of  evidence  is  too  great 
to  be  denied.  One  or  two  or  three  such  cases  may  not  be 
syphilitic;  but  the  great  majority  of  them  surely  are. 

To  study  the  duration  of  secondary  symptoms  accurately 
it  is  necessary,  however,  to  distinguish  the  extraordinary 
from  the  routine,  and  not  to  be  misled  by  such  cases  as  these 
into  the  belief  that  any  large  proportion  of  syphilitics  have  sec- 
ondaries of  more  than  a  few  years'  duration.  A  fair  estimate 
of  the  usual  expectancy  in  this  regard  may  be  gathered  from 
the  following  tabulation  of  successive  cases : 

DURATION    OF    SECONDARY    SYMPTOMS    IN    280    CASES 

Less  than  i  year 17  cases 

1  to  2  years 82     " 

2  to  3  years 79     " 

3  to  4  years 25     " 

Less  than  4  years  ' 49     " 

4  years 17     " 

5  years 6     " 

6  years 2     " 

7  years i  case 

8  years i     " 

9  years i     " 

Total 280  cases 

Thus  in  the  great  majority  of  cases  the  secondary  symp- 
toms cease  to  recur  within  three  years,  in  some  ten  per  cent 
they  recur  after  the  fourth  year,^  in  some  two  per  cent  after 
the  sixth,  and  surely  very  rarely  after  the  tenth  year. 

*  Duration  not  quite  accurately  known. 

2  Foumier  estimating  from  19,000  cases  places  this  at  about  6  per  cent. 
Tamowski  estimates  80  per  cent  in  the  first  four  years,  17  per  cent  from  fifth 
to  tenth;  2.5  per  cent  from  tenth  to  fifteenth,  and  0.5  per  cent  thereafter. 


92  THE    COURSE   OF   SYPHILIS 

On  the  other  hand,  in  tabulating  about  2,500  cases,  I  find 
late  secondaries  (i.e.,  at  or  after  four  years)  in  227;  about 
nine  per  cent. 

LATE    SECONDARIES    AMONG    2,500    CASES 

4  years 51  cases         17  years i  case 

5  "      44    "  18      "      2  cases 

6  "      ;?4    "  iQ      "      I  case 

4  cases 
I  case 

g  ■•  14  ••  23  ■"  2  cases 

10  "  9  "  24  "  I  case 

11  "  8  "  25  "  - .  - .  4  cases 

12  "  II  "  30  "  lease 

13 


44 

18 

34 

" 

19 

13 

'^ 

20 

II 

ti 

21 

14 

u 

23 

9 

" 

24 

8 

" 

25 

II 

u 

30 

8 

" 

I 

case 

Te 

4 

cases 

Fo 

2 

u 

14  "   " I  case  Tenth  to  thirtieth  years 60  cases 

15  "      4  cases        Fourth  to  ninth  years 167 

16  "      

Total 227  cases 

Of  these  cases,  one  half  stopped  in  less  than  seven  years, 
three  quarters  in  ten  years.  About  one  tenth  had  secondary 
symptoms  after  the  thirteenth  year.  This  represents  surely 
less  than  one  per  cent  of  all  cases ;  for  freaks,  seek  the  specialist. 

From  all  of  which  we  may  conclude  that  while  there  is  no 
absolute  term  to  relapses  of  secondary  symptoms,  no  "  sec- 
ondary period "  of  syphilis,  yet  secondary  symptoms  cease 
within  the  first  four  years  in  about  ninety  per  cent,  within  six 
or  seven  years  in  about  ninety-five  per  cent.  Secondary  symp- 
toms appearing  later  than  the  tenth  year  are  the  rarest  excep- 
tions. 

Regions  Involved  by  Late  Secondaries. — Excepting 
one  case  of  double  iritis,  all  the  lesions  recorded  affected  the 
skin  or  the  mucous  membranes.  In  the  following  list  there 
are  many  duplicates,  owing  to  the  fact  that  a  given  case  may 
show  simultaneous  or  successive  secondary  lesions  of  different 
tissues  (e.  g.,  Case  XIV)  : 


THE    SECONDARY   SYMPTOMS  93 

Palms 120  lesions  Throat 26  lesions 

Soles , 24     "  Mouth 26      " 

Scrotum 10      "  Tongue  i 81      " 

Penis 7      "  Double  iritis i  lesion 

Nails 7      "  

Other  parts  of  skin 121      "  Total, 423lesions^ 

Nature  of  the  Late  Secondaries. — Almost  all  the  skin 
lesions  are  squamous,  papular,  or  crusted.  Late  macular 
syphilids  were  noted  thrice  in  the  third  year,  once  in  the  fifth. 
Condylomata  were  not  seen  later  than  the  third  year,  but  mu- 
cous papules  of  the  penis  were  noted  once  in  the  sixth  year; 
pustules  in  the  seventh,  eighth  (twice),  eleventh,  and  thirtieth 
years  (Case  XIV)  ;  vesicles  once  in  the  seventh  year. 

The  late  secondary  syphilids  of  the  mucous  membranes  are, 
as  Fournier  state,  usually  of  a  purely  erosive  type.  The  mu- 
cous papule  is  rare.  Thi-ee  fourths  of  these  mucous-membrane 
lesions  (55  out  of  75)  were  noted  within  the  first  six  years 
of  the  disease. 

The  Infectiousness  of  Late  Secondary  Syphilids. — 
How  rare  late  infections  actually  are  has  already  been  noted; 
how  often  they  are  possible  it  would  be  hard  to  say.  The  in- 
fectiousness of  secondary  lesions  is  unmistakable;  yet  the  im- 
possibility of  contagion  from  a  dry  skin  lesion  is  equally  cer- 
tain; and  it  is  precisely  these  dry  skin  lesions  that  make  up 
almost  the  whole  tale  of  late  secondary  syphilis.  The  only 
noteworthy  exceptions  are  the  mucous-membrane  lesions.  That 
these  are  a  real  source  of  danger  is  shown  by  the  fact  that  many 
of  the  intimately  studied  cases  of  late  infection  have  been  traced 
to — a  kiss.  Thus  does  the  lapse  of  time  purify  even  venereal 
disease. 

Among  the  many  instances  of  late  infection  cited  by  Four- 


>  The  tongue  lesions  are  so  casually  recorded  that  almost  half  have  been 
rejected  as  too  indefinite  for  tabulation. 
'Among  227  cases. 


94  THE    COURSE    OF   SYPHILIS 

nier,  the  following,  observed  by  Spillmann,  is  peculiarly  in- 
structive : 

Case  XVII. — Chancre  in  1871,  followed  by  secondary  symp- 
toms of  skin  and  mouth.  Treatment  for  four  years.  He  marries 
in  1876.  The  first  child  is  born  and  remains  clean  to  his  twenty- 
sixth  year.  Shortly  after  the  birth  of  this  child  the  father  be- 
comes an  inveterate  smoker,  and  soon  his  tongue  shows  syphi- 
litic erosions.  Warned  on  several  occasions  of  the  danger  to 
which  these  lesions  expose  his  wife,  he  nevertheless  continues  to 
smoke,  and  the  erosions  multiply.  At  last,  in  1880,  the  expected 
happens ;  the  wife  develops  chancre  of  the  lower  lip,  followed  by 
secondary  lesions.  Being  pregnant,  she  aborts,  and  later  bears 
two  syphilitic  children. 

Note  the  striking  points  of  this  case.  In  the  fifth  year  of 
the  disease  the  patient  marries  and  proves  that  he  is  not  infec- 
tious by  "having  a  healthy  child.  Later  he  becomes  an  invet- 
erate smoker  and  promptly  the  tongue  relapses.  But,  although 
the  tongue  is  constantly  sore,  it  is  several  years  before  he  in- 
fects his  wife  in  the  ninth  year  of  his  disease.  Recrudescence 
of  lesions  from  smoking  and  relatively  slight  infectiousness  of 
these  lesions — such  are  the  morals  of  this  case. 

The  Prevention  of  Late  Secondary  Lesions. — To  a 
certain  extent  the  recurrence  of  late  secondary  lesions  is  not 
preventable.  That  adequate  early  treatment  is  not  an  abso- 
lute preventive  is  shown  by  Case  XVII,  while  Cases  XIII  and 
XIV  show  relapses  in  spite  of  numerous  short  courses  of  treat- 
ment extending  over  many  years.  Indeed,  Fournier  believes 
that  early  treatment  may  inhibit  subsequent  tertiary  lesions  or 
may  merely  attenuate  them  and  permit  them  to  appear  as  sec- 
ondary lesions. 

I  cannot  quite  agree  with  this  view.  Adequate  early  treat- 
ment does  not  wholly  inhibit  late  tertiaries  or  late  secondaries. 
But  it  does  inhibit  both  in  great  measure  and  in  proportion  to 
its  intelligent  application,  other  things  being  equal.     My  clin- 


THE   TERTIARY   SYMPTOMS  95 

ical  impression  is  entirely  in  accord  with  Neumann's  theory 
that  every  active  syphihtic  lesion  is  potentially  a  focus  of  incu- 
bation for  a  subsequent  outbreak,  and  hence  it  is  much  more 
important  in  the  early  stages  of  the  disease  that  the  symptoms 
be  vigorously  combated  and  promptly  conquered  than  that  the 
patient  should  follow  what  is,  after  all,  but  a  theoretical  sys- 
tem of  mercurial  treatment  based  on  eminently  fallible  observa- 
tion of  the  most  elusive  and  contradictory  of  diseases. 

Such  treatment,  the  detail  of  which  will  be  discussed  later, 
is  surely  calculated  to  inhibit  relapses  of  all  sorts,  secondary 
as  well  as  tertiary. 

But  of  even  greater  importance  as  regards  the  late  infec- 
tious buccal  and  pharyngeal  syphilids  is  the  abuse  of  tobacco. 
The  constant  smoker  cannot  get  an  adequate  prophylaxis  from 
any  treatment,  however  intense,  however  prolonged.  The  irri- 
tation of  tobacco  is  a  menace,  varying  very  widely  and  often 
surprisingly  slight ;  yet  it  is,  of  all  the  causes  of  late,  infectious, 
secondary  lesions,  the  most  important  as  well  as  the  most 
unnecessary.  Tobacco  is  to  late  infectious  secondary  lesions 
what  alcohol  is  to  late  tertiary  lesions. 

THE   TERTIARY   SYMPTOMS 

Definition. — Those  lesions  of  syphilis  which  are  localized 
and  destructive  of  tissue  are  called  tertiary.  They  consist  of 
relatively  diffuse  infiltrations  terminating  in  the  production  of 
masses  of  scar  tissue  or  of  reatively  localized  masses  (gum- 
mata)  tending  to  central  caseation.  The  tertiary  lesions  show 
little  tendency  to  heal  spontaneously^  but  spread  to  the  sur- 
rounding tissue,  advancing  in  a  circular  or  circinate  way  and 
destroying  every  tissue  encountered  in  truly  malignant  fashion. 

A  severe  outbreak  of  tertiary  lesions  may  undermine  the 
patient's  general  condition,  and  prolonged  suffering  from  such 
lesions  may  give  rise  to  amyloid  or  sclerotic  changes  in  the  vis- 


96 


THE    COURSE    OP    SYPHILIS 


cera.  But  in  this  regard  syphilis  does  not  differ  from  other 
chronic  inflammations.     There  is  no  specific  tertiary  toxemia. 

Occurrence. — The  majority  of  cases  of  syphihs  as  we 
see  it  to-day  do  not  have  any  tertiary  lesions.  Among  my 
2,500  cases,  in  1,024  (forty-one  per  cent)  ^  tertiary  lesions 
are  recorded;  of  these,  106  in  women. 

Tertiary  lesions  may  appear  at  any  time  after  the  secondary 
incubation.  They  may  even  precede  the  secondary  symptoms. 
But  this  tertiarisme  d'emhUe,  as  the  French  call  it,  is  most  ex- 
ceptional. (Case  XXVII,  page  231,  in  which  only  a  few  neg- 
ligible secondary  symptoms  preceded  the  development  of  a 
gumma,  is  an  excellent  example.)  Yet  it  is  by  no  means  un- 
usual for  tertiary  lesions  to  appear  during  the  first  year  of 
the  disease — but  the  conditions  may  be  best  expressed  in  fig- 
ures, and  accordingly  I  annex  two  tables,  Fournier's,the  larger, 
drawn  from  a  private  practice  in  Paris;  mine,  the  smaller, 
drawn  from  a  similar  source  in  X^ew  York : 

INCIDENCE    OF    TERTIARISM 


Fournier 


Keyes 


First  year 278 

Second  year 453 

Third  year 471 

Fourth  year 388 

Fifth  year 357 

Sixth  year 326 

Seventh  year 2  74 

Eighth  year 211 

Ninth  year ;  195 

Tenth  to  fourteenth  years 736 

Fifteenth  to  nineteenth  years 423 

Twentieth  to  twenty -ninth  years 304 

After  the  twenty-ninth  year B)2, 

Total I  4,499 


112 
149 
142 

79 
61 

64 
39 
25 
20 
80 
26 

23 

4 


824 


^  Certain  authorities  record  as  low  as  ten  per  cent  tertiaries  in  cases  treated 
by  certain  methods.  But  I  am  not  dealing  with  syphilis  as  treated  by  us,  but 
with  syphilis  as  seen  by  us — with  syphilis  as  it  exists  in  the  United  States  to-day. 


THE   TERTIARY   SYMPTOMS  97 

Observe  that  tertiaries  make  their  appearance  more  often 
in  the  second  and  third  years  of  the  disease  than  in  any  other 
two  years;  that  even  in  the  first  year  they  are  by  no  means 
uncommon  (six  per  cent,  Fournier;  thirteen  per  cent,  Keyes)  ; 
that  in  half  the  cases  they  appear  first  within  three  (Keyes) 
to  seven  (Fournier)  years  after  the  chancre;  that  the  be- 
ginning may  be  deferred  for  an  almost  indefinite  time. 
Among  my  cases  the  four  longest  deferred  began  at  thirty 
(twice),  thirty-one,  and  forty  years:  Fournier  records  two 
at  forty-six,  and  one  each  at  fifty-two,  fifty-four,  and  fifty- 
five  years  after  the  chancre.  Manifestly,  the  tertiary  "  pe- 
riod," like  the  secondary  "  period  "  of  the  disease,  begins 
with  the  chancre  and  ends  with  the  patient.  Yet  the 
rule  that  secondary  symptoms  usually  cease  ere  tertiary 
ones  begin  is  clinically  true  and  is  supported  by  a  compari- 
sion  of  the  above  statistics  with  those  on  the  duration  of  sec- 
ondary symptoms. 

Relapses. — The  intermittent  or  relapsing  character  of 
syphilis  is  most  evident  in  its  tertiary  lesions.  Relapses  of 
secondary  lesions  usually  occur  at  relatively  short  intervals  of 
a  few  months ;  tertiary  relapses  at  longer  intervals. 

Among  307  cases  of  relapsing  tertiaries  which  I  have 
analyzed,  115  relapsed  once,  'j'j  twice,  30  thrice,  6  four  times, 
5  five  times,  2  six  times,  i  eight  times. 

(The  intervals  between  relapses  may  be  tabulated  as  on 
page  98.) 

Thus  about  one  third  of  the  cases  of  tertiarism  relapsed, 
and  about  half  of  these  relapsing  cases  recurred  no  more  after 
two  years.  Yet  in  this  matter  statistics  are  almost  meaning- 
less, for  averages  do  not  affect  individuals. 

How  widely  the  course  of  tertiarism  fluctuates  may  be 
inferred  from  the  contrast  of  Cases  IV,  VI,  VII,  and  XXVII 
(pages  19,  231)  of  early  tertiarism  with  the  following  four 
typical  examples  of  late  and  protracted  tertiarism : 


98 


THE   COURSE   OF   SYPHILIS 


INTERVALS   BETWEEN    TERTIARY   RELAPSES 


Less  than  i  year  ^ 

1  year 

2  years 

3  "  

4  " 

5  "  

6  "  

7  "  

8  "  

9  "  

10  ■'   

11  "   

12  "  

13  "  

14  "  

15  "  

16  "  

17  "    

18  "    

25  "    

26  "    

28   "    

Total  number  of  cases 


First 
Relapse 


37 
99 
51 
41 
13 
15 

7 
10 

6 


307 


Subsequent 
Relapses 


13 
71 
42 
29 
II 

5 
4 
3 
4 
o 

5 
2 


Total 


50 
170 

93 
70 
24 
20 
II 

13 
10 

5 

13 
6 

I 
3 
3 

I 
2 

I 

I 
I 
I 


Case  XVIII. — Tertiary  lesions  of  larynx  and  hones  beginning 
after  forty  years.  October  21,  1886.  The  patient  is  a  physician 
sixty-five  years  of  age.  He  relates  that  in  1843,  while  a  medical 
student,  he  acquired  what  proved  to  be  a  chancre  in  the  usual 
way.  The  sore  was  burned  with  nitrate  of  silver  and  he  took  a 
few  five-grain  blue  pills — not  more  than  six,  he  thinks — and  no 
other  treatment  whatever.  For  forty  years  he  remained  entirely 
well,  and,  though  a  practicing  physician,  noted  upon  himself 
nothing  attributable  to  syphilis. 

In  1883  his  voice  became  husky,  the  diagnosis  of  tuberculosis 
was  made,  and  he  went  to  the  Adirondacks.  After  a  year's  resi- 
dence there  his  voice  had  improved,  but  he  suffered  from  severe 
nasal  catarrh  and  lost  a  piece  of  the  septum.    Then  a  large  node 

1  Many  apparent  relapses  within  a  year  are  merely  recrudescence  of  un- 

cured  lesions. 


THE   TERTIARY   SYMPTOMS 


99 


appeared  on  the  lower  part  of  the  right  tibia,  another  in  the 
upper  frontal  region.  The  latter  ulcerated,  but  he  took  a  little 
iodid  of  potassium  and  it  promptly  healed.  A  second  ulcer  then 
appeared  in  the  frontal  region  below  the  former  one.  This  has 
been  open  for  a  year.  There  is  bare  bone  at  the  bottom  about 
one  cm.  square.  He  was  sent  home,  taking  iodid  of  potassium, 
and  has  not  been  seen  since. 

Case  XIX. — Malignant  relapsing  syphilis  after  tzventy  years. 
Chancre  in  1855,  at  the  age  of  twenty-four.  Early  treatment  a 
few  months,  chiefly  or  wholly  by  iodid  of  potash.  He  married 
and  had  healthy  children,  and  no  further  symptoms  of  syphilis 
until  1875.  Then  gummata  of  tibia  and  ulna,  treated  and  cured 
by  Dr.  Van  Buren  (who  introduced  him  into  catheter  life  at  the 
same  time). 

In  1879  enormous  gumma  of  left  thigh.  Treated  by  my 
father.    Well  in  April,  1880. 

In  August,  1880,  gumma  of  right  buttock,  then  some  tuber- 
cular skin  lesions.    Cured  in  March,  1881. 

In  July,  1881,  gumma  of  right  calf;  in  November,  gumma  of 
skull.     Cured  in  December,  1883. 

In  July,  1883,  acute  suppurative  nephritis  with  edema  of 
lungs.  He  resumed  mixed  treatment,  and  in  January,  1884,  was 
well  so  far  as  subjective  symptoms  were  concerned.  But  the 
urine  continued  purulent,  catheter  life  continued,  and  in  April, 
1884,  he  had  another  edema.  Last  seen  in  July,  1884.  No  fur- 
ther symptoms  of  syphilis.     He  probably  died  soon  after. 

Case  XX. — Secondary  symptoms  relapse  twenty  years:  ter- 
tiaries  from  the  fourth  to  the  twenty-second  year.  Chancre  in 
1870,  at  the  age  of  thirty-three.  Early  symptoms  light.  Quality 
of  treatment  not  stated.  First  seen  in  1874  with  a  scaly  eruption 
of  the  scrotum,  a  pearly  patch  on  the  side  of  the  tongue,  a  little 
interstitial  thickening  of  both  tonsils,  and  thin,  ribbed,  eczema- 
tous-looking  nails.  He  gave  an  eczematous  family  history,  and, 
accordingly,  was  tried  on  arsenic  and  local  treatment.  But  he 
began  to  lose  weight,  the  lesions  did  not  improve,  and  in  June  he 
was  therefore  put  on  mixed  treatment.  This  he  took  quite 
faithfully,  yet  the  scrotum  grew  worse,  became  pustular,  and 
finally  ulcerated  in  July,  1875.  A  sharp  course  of  iodid  healed 
these  ulcers  in  two  weeks. 
9 


lOO  THE   COURSE    OF    SYPHILIS 

A  month  later  a  typical  chancre  redux  appeared,  resembling 
a  chancre  in  every  respect.  But  there  had  been  no  exposure  for 
a  year,  and  there  was  no  adjacent  adenitis.  It  was  followed, 
however,  by  a  few  papules  on  the  hands,  some  squamous  patches 
on  the  legs,  and  more  pearly  spots  on  the  tongue.  In  January, 
1876,  all  was  well  except  the  tongue.     Nails  still  ridged. 

Though  he  kept  up  treatment,  with  never  more  than  a  month 
intermission,  new  spots  continued  to  appear  on  the  tongue,  and 
in  January,  1877,  after  much  facial  neuralgia,  a  gumma  devel- 
oped "  high  up  under  the  left  temporal  muscle."  By  March  this 
was  under  control. 

In  July,  1877,  he  complained  of  drowsiness,  diffuse  pain  over 
the  side  of  the  head,  and  some  nervous  excitability.  This  was 
followed  by  alternating  diarrhea  and  constipation  and  slight  left 
ptosis.     Treatment  resumed  to  November,  1878. 

In  January  and  November,  1879,  and  in  April,  1880,  he  took 
short  courses  of  mixed  treatment  for  facial  neuralgia  and  "  the 
old  congestive  painful  attacks  in  the  abdomen."  Yet,  in  Novem- 
ber, 1880,  tongue  and  scrotum  (scales)  relapsed,  and  a  few  weeks 
later  he  lost  his  voice  from  infiltration  about  the  arytenoids  and 
vocal  cords.     These  symptoms  were  relieved  by  February,  1881. 

In  April,  1881,  a  relapse  of  facial  pain,  tenderness,  and  edema 
called  for  more  treatment. 

In  September,  1882,  several  gummata  appeared  in  the  tongue, 
followed  in  January,  1883,  by  depapillating  glossitis.  This  was 
cured  by  the  end  of  1884. 

In  September,  1885,  tubercles  on  fingers.     Prompt  cure. 

In  June,  1887,  interstitial  glossitis  and  erosions  on  tongue. 
These  continue  to  relapse  until  1890  in  spite  of  treatment. 

In  1892  the  intestinal  attacks  returned,  a  mass  was  discov- 
ered, and  operation  advised.  Accordingly,  Dr.  Stimson  explored, 
and  finding  a  large  growth  obstructing  the  gut,  made  a  lateral 
anastomosis  and  gave  a  bad  prognosis.  Undismayed  by  this,  and 
unaided  by  any  antisyphilitic  treatment,  he  promptly  recovered 
from  the  operation,  and  when  he  next  reported,  in  February, 
1898,  the  lump  had  disappeared,  and  he  was  well  but  for  a  little 
gout.  And  since  then  the  syphilis  has  ceased  to  relapse.  (Last 
seen  in  1904.) 

Was  the  intestinal  tumor  syphilitic?     I  believe  it  was. 


THE   TERTIARY   SYMPTOMS  lOI 

Case  XXI. — Interval  of  twenty-eight  years  between  tertiary 
relapses.  Chancre  in  1846,  at  the  age  of  twenty-nine.  Took 
mercury  constantly,  until,  in  1854,  he  lost  the  greater  part  of 
both  hard  and  soft  palates  and  was  gravely  debilitated.  Cured 
in  two  years  by  heroic  doses  of  iodids.  No  relapse  until  May, 
1882.  Then  some  papules  appeared  on  the  index  finger  of  the 
right  hand.  These  spread  rapidly,  and  when  first  seen,  four 
months  later,  there  was  a  tuberculo-ulcerative  syphilid  extending 
from  hand  to  elbow.     Cured  in  one  year  by  mixed  treatment. 

The  Effect  of  Treatment. — Such  cases  surely  prove 
the  lawlessness  of  syphilis.  Be  it  noted,  however,  that  the 
efficiency  of  treatment  is  the  determining  factor  in  tertiary 
relapses.  If  a  tertiary  lesion  remains  untreated  it  will,  sooner 
or  later,  be  followed  by  other  tertiary  manifestations.  If  in- 
efficiently treated,  it  may  be  temporarily  controlled,  but  other 
relapses  soon  occur  (Cases  XIX,  XX) — hence  the  frequency 
of  relapses  within  three  years.  If  efficiently  treated,  future 
relapses  will  probably  be  altogether  prevented,  certainly  indefi- 
nitely delayed  (Case  XXI).  Happily,  our  understanding  of 
and  equipment  for  efficient  treatment  have  advanced  greatly  in 
the  last  quarter  of  a  century. 

But,  if  the  treatment  of  a  given  tertiary  outbreak  must  be  so 
administered  as  to  prevent  relapses,  it  is  manifestly  even  more 
important  that  the  early  routine  treatment  be  so  ordered  as  to 
prevent  any  tertiary  outbreak  whatever — if  that  be  possible. 

Let  it  be  confessed  at  once — such  prevention  cannot  be 
absolute.  In  Case  XXVII,  for  example,  no  conceivable  fore- 
sight could  have  forestalled  the  tertiary  lesion,  though  vigorous 
treatment  earlier  applied  would  have  checked  it  sooner.  So, 
in  a  lesser  degree,  many  instances  of  tertiarism  in  the  first 
years  of  the  disease  are  unpreventable.^     But  after  the  fifth 

*  Absolute  prevention  of  tertiaries  cannot  be  achieved  by  any  treatment. 
The  ideal  minimum  claimed  by  certain  Continental  authorities  is  ten  per  cent 
of  tertiaries. 


I02  THE   COURSE    OF    SYPHILIS 

year    the   well-treated   case   may   expect   no    further   tertiary 
lesions. 

What,  then,  constitutes  "  good  treatment  "  ?  Mercury  and 
hygiene.     And  each  of  these  is  twofold,  thus : 

1.  Mercury  (a)  sufficient  in  quantity  and  administered 
long  enough  to  control  the  average  case;  (b)  sufficient  in  quan- 
tity and  with  the  aid  of  iodids,  tonics,  or  whatever  else  be  re- 
quired to  control  promptly  all  secondary  or  tertiary  manifesta- 
tion. 

2.  Hygiene  (a)  especially  abstinence  from  alcohol  and 
such  moderation  as  may  be  necessary  in  the  use  of  tobacco; 
(b)  in  general,  the  avoidance  of  such  deleterious  influences  as 
disease,  overexertion — especially  the  overstrain  of  so-called 
"  modern  life,"  be  the  dissipation  business  by  day  or  pleasure 
by  night — and  trauma. 

Discussion  of  these  matters  does  not  belong  here.  But  if 
the  rules  laid  down  (page  139)  are  obeyed,  the  patient  has 
nine  chances  in  ten  of  escaping  tertiary  lesions  after  the  fourth 
year  of  his  disease.  This  statement  I  should  gladly  support  by 
statistics,  but  that  statistics  are  lacking.  I  have  no  close  rec- 
ord of  the  manner  of  life  followed  by  my  patients.  For  ex- 
ample, less  than  one  per  cent  of  them  are  denominated  "  alco- 
holic " — surely  an  optimistic  estimate. 

Yet  I  have  a  general  record  of  the  duration  of  the  early 
treatment  in  523  non-alcoholic  cases  which  developed  tertiaries. 
Of  these,  292  were  under  mercurial  treatment  at  least  eighteen 
months,^  231  for  a  less  time.  The  duration  of  tertiaries  in  the 
former  class  ^  was  less  than  five  years,  sixty  per  cent ;  five  to 
ten  years,  twenty  per  cent;  ten  to  fifteen  years,  four  per  cent; 
over  fifteen  years,  six  per  cent ;  for  the  latter  class  -  respectively 
thirty  per  cent,  thirty-three  per  cent,  twenty-one  per  cent,  and 
sixteen  per  cent. 

1  Yet  many  of  these  were  by  no  means  efficiently  treated. 
=*  Exclusive  of  known  alcoholics. 


THE   TERTIARY   SYMPTOMS  103 

The  Effect  of  Alcohol. — I  have  said  above  that  tobacco 
is  to  late  infectious  secondaries  what  alcohol  is  to  late  tertiaries. 
Let  me  insist  on  the  converse  proposition  :  Alcohol  is  to  late  ter- 
tiaries what  tobacco  is  to  late  infectious  secondaries.  Every 
syphilitic  smoker  does  not  have  an  eroded  tongue,  nor  does 
every  syphilitic  drinker  continue  to  have  relapsing  tertiaries.  I 
have  known  several  men  to  drink  themselves  to  death  many 
years  after  their  last  syphilitic  lesions  had  disappeared.  Yet 
close  observation  will  show  not  only  that  the  man  who 
drinks  hard  is  the  worst  sufferer  from  tertiary  syphilis,  but 
also  that  he  who  merely  absorbs  constantly — faithfully,  one 
might  say — two  or  three  drinks  a  day  is  a  far  more  prom- 
ising candidate  for  tertiarism  than  he  who  drinks  nothing 
at  all. 

More  than  this :  In  sensitive  subjects  I  have  several  times 
(sufficiently  often  to  convince  both  the  patient  and  myself  that 
this  was  no  mere  coincidence)  noted  distinct  exacerbation  of 
existing  lesions  within  forty-eight  hours  after  the  patient  had 
taken  two  or  three  glasses  of  beer  or  whisky.  By  keeping 
a  sharp  lookout  for  such  occurrences,  one  notes  them  with 
startling  frequency,  and  one  readily  convinces  the  patient  of 
the  evil  effect  of  even  a  little  drink.  I  grow  yearly  more  con- 
vinced that  the  syphilitic  who  wishes  to  insure  himself  against 
relapses  must  drink  neither  habitually  nor  intemperately.  An 
occasional  drink  is  permissible;  but  it  is  safest,  all  things  con- 
sidered, that  he  drink  not  at  all. 

Statistically,  my  113  recorded  alcoholics  stand  almost  on 
a  par  with  the  insufficiently  treated  cases  (see  above)  with 
semidecennial  percentages  of  thirty-four,  thirty-two,  nineteen, 
and  fifteen. 

Regions  Involved. — No  tissue  is  exempt  from  tertiary 
syphilis.  The  same  is  doubtless  true  of  secondary  syphilis; 
but  the  transitory  congestive  or  exudative  secondary  lesion 
passes  and  leaves  no  trace ;  while  the  persistent  and  destructive 


io4 


THE    COURSE   OF    SYPHILIS 


tertiary  lesion,  even  though  it  be  cured,  leaves  a  permanent 
scar  to  attest  its  passage. 

It  were,  therefore,  futile  to  enumerate  in  detail  the  lesions 
I  have  observed;  another  few  thousand  cases  would  show 
altogether  different  proportions.  In  the  main,  however, 
one  may  separate  them  into  four  classes  in  the  following 
proportions :  Lesions  ^  of  the  skin  and  subcutaneous  tissue, 
thirty-one  per  cent  (544  cases)  ;  lesions  of  the  nervous 
system,  thirty-one  per  cent  (598  cases)  ;  bone  lesions  (includ- 
ing nose  and  palate),  seventeen  per  cent  (302  cases)  ;  lesions 
of  the  viscera  and  mucous  membranes,  seventeen  per  cent 
(308  cases). 

It  is  surprising  to  find  lesions  of  bone  so  few  and  lesions, 
of  the  nervous  system  so  many.     Yet  the  statistics  of  other 
observers  show  about  the  same  proportions. 

But  in  statistics  of  this  sort,  which  after  all  chiefly  con- 
cern the  patient,  it  seems  unfair  to  separate  tertiary  symptoms 
from  late  secondaries  and  parasyphilids ;  they  are  all  one  to 
him.  I  have,  therefore,  included  all  these  in  the  following 
table,  made  up  in  percentages  from  2.231  recorded  lesions 
(occuring  at  or  after  the  third  year,  and  including  all  ter- 
tiaries,  upon  1,330  cases). 


INCIDENCE    OF    ALL    LATE    LESIONS 


To  5 
Years 

5  to  10 
Years 

10  to  15 
Years 

15  to  20 
Years 

Over 
20  Years 

Grand 
Average 

Skin,  etc 

Per  cent 
43 
23 
13 
21 

Per  cent 
38 

27 

13 
22 

Per  cent 
29 
33 
15 
2Z 

Per  cent      Per  cent 
31                .-^2 

Per  cent 
37 

Nervous  system . . . 
Bones 

34 
10 

25 

32 
12 

24 

27 
14 

Other  tissues 

22 

Total  number  of 
lesions 

1,018 

642 

zn 

106 

152 

2,231 

'  Counting  an  eruption,  even  though  it  appears  first  in  one  part  of  the  body, 
then  in  another,  a  single  lesion. 


THE   PARASYPHILIDS    OR    SYPHILITIC   DYSTROPHIES    105 

Thus,  although  the  number  of  lesions  decreases  by  about 
half  with  each  five-year  period,  lesions  of  the  nervous  system 
are  proportionately  little  more  and  lesions  of  the  skin  little  less 
frequent  after  the  tenth  year  of  the  disease  than  before  this, 
wdiile  the  proportion  of  bone  lesions  remains  about  the  same 
throughout.  Bone  syphilis  owes  its  horror  rather  to  its  dis- 
figurement than  to  its  frequency. 


THE  PARASYPHILIDS  OR  SYPHILITIC  DYSTROPHIES 

Definition. — The  parasyphilids  or  syphilitic  dystrophies 
are  lesions  or  functional  derangements  for  which  pathology 
shows  no  syphilitic  basis  and  for  which  the  antisyphilitic  spe- 
cifics afford  little  or  no  relief.  They  are  apparently  toxic  in 
origin,  and  may  be  caused  by  various  forms  of  systemic  intoxi- 
cation. This  systemic  intoxication  is  usually,  though  not  neces- 
sarily, syphilis — syphilis  implanted  upon  a  soil  harrowed  by  an 
evil  heredity  or  fertilized  by  debility  due  to  such  causes  as 
malnutrition,  excessive  mental  or  physical  strain  or  debauch. 

Varieties. — Thus  the  parasyphilids,  or  syphilitic  dys- 
trophies, include  all  conditions  zvhich,  without  being  patholog- 
ically syphilitic,  are  clinically  due  to  syphilis.  Their  name  is 
legion.  Case  XX,  showing  "  eczematous-looking "  nails, 
apparently  due  to  syphilis,  and  yet  persisting  after  the  truly 
syphilitic  lesions  had  been  cured,  is  an  excellent  example  of  a 
large  and  entirely  indefinite  class  of  conditions  bearing  no 
special  hall-mark  of  syphilis,  and  yet  arising  during  the  active 
period  of  the  disease.  In  the  patient's  mind  such  lesions  are 
truly  syphilitic :  Thus  one  man  tells  me  his  skin  "  has  never 
been  the  same  '' — another  that  the  texture  of  his  hair  or  nails 
has  changed — since  his  syphilis.  Another  feels  his  spirit 
broken  or  his  vitality  gone;  he  never  has  regained  the  weight 
lost  during  the  first  months  of  the  disease ;  he  has  been  afiflicted 
with  neuralgic  headaches  ever  since  the  disease  began.     An- 


io6  THE    COURSE    OF    SYPHILIS 

other  has  become  hysterical  or  neurasthenic  or  syphilobic  to  an 
insane  degree. 

Are  these  functional  or  dystrophic  conditions  truly  syphi- 
litic in  origin?  Clinically,  yes.  Syphilis  is  undoubtedly  the 
exciting  cause.  And  yet  in  many  such  instances  one  feels 
assured  that  the  constitution  of  the  patient  is  much  more  at 
fault  than  the  syphilis.  The  same  rough  skin  or  impaired 
vitality  might  have  resulted  from  typhoid  fever  or  from  a 
severe  mental  shock  or  from  prolonged  malnutrition.  The 
disorder  is  a  functional  disturbance  of  the  nervous  system 
evoked  by  syphilis,  but  whether  evoked  by  terror  or  by  toxin, 
it  is  often  impossible  to  say. 

1.  Such  is  a  large  vague  group  which  will  or  will  not  be 
classed  as  syphilitic  dystrophies,  according  as  the  physician  is 
materialist  or  idealist. 

2.  Again,  there  are  a  number  of  conditions  manifestly  not 
neurotic  in  origin,  and  of  which  syphilis,  like  any  other  chronic 
toxemia,  may  be  the  cause.  Arteriosclerosis  comes  first  to  mind, 
and  with  it  interstitial  sclerosis  of  any  viscus.  Fournier  would 
add  certain  cases  of  epilepsy,  glycosuria,  etc.  Indeed,  this  class 
of  cases  is  but  little  less  broad  and  vague,  but  little  more  closely 
and  essentially  allied  to  syphilis  than  the  preceding  one. 

3.  In  a  third  class,  and  strikingly  emphasized  by  their  fre- 
quency, their  fatality,  and  their  almost  constant  association 
with  syphilis,  are  tabes  dorsalis,  paresis,  and  Erb's  spastic 
spinal  paralysis.     These  are  the  parasyphilids  par  excellence. 

4.  In  a  fourth  class  are  the  defects  of  development  im- 
parted by  hereditary  and  to  a  less  degree  by  infantile  syphilis. 
These  will  be  considered  with  the  other  special  lesions  of  hered- 
itary syphilis  (page  532). 

5.  Finally  ascending  the  scale  and  reaching  lesions  more 
peculiarly  and  essentially  syphilitic,  and  yet  not  bearing  the  full 
pathological  imprint  of  the  disease,  we  may  mention  the  pig- 
mentary syphilid  (page  300)  and  certain  acute  neurasthenias 


THE    PARASYPHILIDS    OR    SYPHILITIC    DYSTROPHIES    107 

of  early  syphilis.  These  were  included  among  the  parasyph- 
ilids  in  Fournier's  classical  monograph ;  but  they  scarcely  de- 
serve this  special  attribution.  Nor  need  buccal  leukoplakia 
(page  352)  and  aneurysm  be  considered  here,  for  these  are 
truly  syphilitic  lesions. 

Tabes  Dorsalis  and  Paresis. — The  wide  divergence  of  mod- 
ern opinion  upon  the  etiology  and  pathology  of  tabes  and 
paresis  is  most  disheartening.  We  do  not  yet  know  whether 
the  two  are  clinical  types  of  a  single  pathological  condition. 
We  do  not  know  whether  they  are  primarily  inflammatory  or 
primarily  degenerative.  Perusal  of  recent  discussions  (espe- 
cially in  relation  to  paresis  ^)  leaves  one  quite  bewildered  and 
destroys  all  the  confidence  engendered  by  reading  the  clear-cut 
opinions  of  any  one  authority. 

■  Seeing  these  diseases  from  a  syphilitic  point  of  view,  I 
naturally  encounter  only  those  of  manifest  syphilitic  origin, 
and,  accordingly,  must  side  with  those  who  believe  tabes  to  be 
almost  always  syphilitic  in  origin,  paresis  frequently  so. 

Etiology. — Syphilis  is  discoverable  in  the  antecedents  of 
ninety  per  cent  to  ninety-five  per  cent  of  tabetics  and  in  about 
fifty  per  cent  ^  of  paretics.  Asylum  statistics  of  paretics  show 
a  relatively  low  proportion  of  syphilis  because  it  is  difficult  to 
obtain  an  accurate  history  after  the  disease  is  far  advanced. 
But  closer  study  of  the  histories  of  paretics  reveals  a  dispro- 
portionate increase  of  syphilitics.  Juvenile  paresis  and  tabes 
are  exclusively  syphilitic. 

Most  authorities  agree  that  syphilis  is  not  the  adequate 
cause  of  either  malady.  "  Syphilis  and  civilization,"  says 
Kraf¥t-Ebing.  And  this  is  the  accepted  doctrine.  Among 
Asiatics  and  Africans,  though  syphilis  be  common,  even  en- 

1/.  Am.  Med.  Ass'n.,  1905,  vol.  xliv,  pp.  1153, 1320, 1413;  N.  Y.  Med.  J., 
1905,  vol.  Ixxxii,  p.  500;  Bull,  de  I'acad.  de  med.,  Paris,  1905,  vol.  Ixix;  La 
Syphilis,  1905,  vol.  iii,  pp.  321,  500,  595,  652,  743,  829. 

2  "Not  more  than  one  half  the  total  number"  (Berkley). 


io8  THE    COURSE    OF    SYPHILIS 

demic,  paresis  and  tabes  are  extremely  rare,  and  apparently  our 
ancestors  could  drink  wine  and  debauch  women  with  little  fear 
of  tabes  at  least.  But  in  our  own  time  both  diseases  grow  more 
and  more  common.  Whereas  women  used  to  suffer  infre- 
quently (i-io),  some  recent  statistics  attribute  the  disease  to 
them  quite  commonly  (1-4,  or  even  higher).  City  folk  are 
more  liable  to  these  diseases  than  their  country  brethren.  The 
age  of  onset  is  between  twenty-five  and  forty-five  years  in  the 
great  majority  of  cases  (seventy-five  per  cent  of  my  tabetics 
and  seventy  per  cent  of  paretics  began  between  the  ages  of 
twenty-eight  and  forty-five).  These  general  facts,  fortified  by 
observation  of  individual  cases,  show  that  "  civilization  "  has 
a  large  share  in  the  etiology  of  tabes  and  paresis;  but  it  is  not 
possible  to  specify  more  closely  than  this.  Lechery  and  liquor 
can  scarcely  be  invoked  as  exclusively  modern  causes  of  disease, 
though  they  are  undoubtedly  contributory  in  certain  cases. 
Heredity  is,  of  course,  blamed  by  some  authorities  and  excul- 
pated by  others.  The  constant  nerve  tension  of  city  life, 
whether  in  the  struggle  of  business  or  in  the  pursuit  of  pleas- 
ure, is  often  the  determining  cause. 

I  have  tabulated  the  relation  with  syphilis  of  123  cases  of 
tabes  and  44  of  paresis,  thus :  ^ 

72  tabetics  and    i  paretic  denied  syphilis, 
were  doubtful, 
confessed  syphilis. 

began  before  the  fifth  year  of  the  syphilis, 
began  between  the  fifth  and  ninth  years, 
began  between  the  tenth  and  fourteenth  years, 
began  between  the  fifteenth  and  nineteenth  years, 
began  after  the  twentieth  year, 
had  suffered  syphilitic  lesions  of  the  nervous  system, 
had  suffered  tertiary  lesions.^ 

•  See  also  table  on  p.  372. 

'  One  other  tabetic  who  denied  syphiHs  had  lost  his  septum  and  showed  a 
palmar  syphilid. 

^  Including  syphilis  of  the  nervous  system. 


10 

li         i 

'      I 

96 

'  38 

8 

'   5 

30 

'  13 

16 

'  9 

8 

'   0 

13 

'   7 

22 

"          ' 

'  10 

41 

'  15 

THE    PARASYPHILIDS    OR    SYPHILITIC    DYSTROPHIES    109 

The  longest  "incubation"  of  tabes  was  32  years;  of  paresis,  25  years;  the 
shortest  of  tabes,  3  years  (6  cases);  of  paresis,  3  years  (3  cases);  the  average, 
of  tabes,  9  years;  of  paresis,  8  years. 

Tabes  occurred  in  about  four  per  cent  of  all  cases  of  syphi- 
lis, paresis  about  one  third  as  often.  My  records  do  not  shbw 
the  bearing  of  early  treatment  or  symptoms  of  syphilis  upon 
the  prospect  of  tabes  or  paresis.  Fournier  alleges  the  early 
symptoms  are  almost  always  light  and  the  treatment  brief. 

Pathology. — In  both  tabes  and  paresis  two  pathological 
conditions  commonly  coexist — viz.  ( i )  degeneration  of  certain 
tracts,  and  (2)  an  interstitial  sclerosis.  The  essential  lesion 
of  tabes  ^  is  commonly  believed  to  be.  degeneration  of  the  sen- 
sory fibers,  chiefly  those  of  the  cord ;  the  interstitial  hyperplasia 
found  at  autopsy  (and  the  motor  degeneration)  being  regarded 
as  incidental  or  secondary.  Yet  a  certain  few  see  in  the  inter- 
stitial changes  a  primary  perivascular  syphilitic  sclerosis. 
Practically  the  same  divergence  exists  in  the-  interpretation 
of  the  pathology  of  paresis.  Those  who  believe  in  the 
syphilitic  nature  of  the  two  diseases  see  in  the  inflammatory 
lesions  evidence  of  actual  syphilitic  change,  but  the  weight 
of  authority  is  against  this  view — at  least  for  the  majority 
pi  cases.  Yet  the  cytologic  changes  of  the  spinal  fluid  so 
common  in  syphilis  are  all  but  constant  in  tabes  and  paresis 
(page  376). 

Yet  a  certain  few  typical  cases  of  tabes  (or  paresis)  prove, 
whether  by  the  success  of  antisyphilitic  treatment  or  by  the 
post-mortem  findings,  to  be  syphilitic  conditions  pure  and  sim- 
ple. They  are  classed  as  syphilitic  pseudo-tabes  (or  pseudo- 
paresis).  Though  various  symptoms  have  been  alleged  as  dif- 
ferentiating these  "  pseudo  "  or  syphilitic  conditions  from  true 
tabes  (or  paresis),  one  encounters  from  time  to  time  cases 
diagnosed  as  one  of  the  latter  conditions  by  competent  neu- 

*  Marie's  suggestion  that  tabes  may  be  a  syphilitic  disease  of  the  lymphatics, 
though  very  attractive,  has  not  been  demonstrated. 


no  THE    COURSE    OF    SYPHILIS 

rologists  which  yet  show  marked  improvement  under  antisyph- 
ilitic  treatment. 

Hence  the  two  important  points  that  concern  the  syphilolo- 
gist  are  ( i )  to  be  always  on  his  guard  against  tabes  or  paresis 
and  able  to  diagnose  them  in  their  incipient  stages,  and  (2) 
after  making  the  diagnosis  to  administer  a  short,  sharp  course 
of  antisyphihtic  treatment  before  consigning  the  patient  to  the 
neurologist. 

Diagnosis. — This  is  no  place  for  a  clinical  study  of  the 
symptoms  of  tabes  and  paresis.  We  must  take  this  for  granted, 
and  set  down  here  only  the  essential  features  of  the  diagnosis. 

The  diagnosis  of  tabes  is  called  for  if  a  syphilitic  complains 
of  sharp  lancinating  (otherwise  inexplicable)  pains  in  any  part 
of  his  body,  or  of  inability  to  urinate,  or  of  increasing  consti- 
pation, or  of  numb  feet  or  stumbling  in  the  dark,  or  of  explo- 
sive diarrhea  or  vomiting  accompanied  by  severe  pain,  or  of 
any  "  eye  trouble,"  or  of  impairment  of  the  sexual  powers. 

The  diagnosis  may  usually  be  made  from  loss  of  knee-jerk 
and  reflex  iridoplegia  (Arg}^ll-Robertson  pupil).  If  one  of 
these  be  absent  and  the  patient  tabetic,  there  will  be  severe  ful- 
gurating pains,  areas  of  paresthesia  or  static  ataxia  (inability 
to  stand  with  heels  and  toes  together  and  the  eyes  shut)  to  re- 
place it.  In  many  instances  the  typical  ataxic  gait  practically 
establishes  the  diagnosis. 

Tabes  may  be  confused  with  pseudo-tabes,  whether  due  to 
syphilis  or  toxic  neuritis.  Toxic  cases  usually  are  distin- 
guished by  an  actual  diminution  in  muscular  power  and  tender 
points  along  the  inflamed  nerves,  neither  of  which  occurs  in 
early  tabes.  Syphilitic  myelitis  should  be  readily  distinguished 
by  the  increased  reflexes  (page  403). 

The  diagnosis  of  paresis  is  much  more  difficult.  "  Think 
twice  before  contenting  yourself  with  a  diagnosis  of  neuras- 
thenia in  a  man  or  a  woman  who  in  middle  life  shows  well- 
defined  reflex  pupillary  disturbance,"  says  Berkeley.     Neuras- 


THE   PARASYPHILIDS   OR   SYPHILITIC   DYSTROPHIES  ill 

thenia,  indeed,  may  be  indistinguishable  from  incipient  paresis 
unless  by  the  very  closest  physical  examination.  Disorders  of 
the  iritic  reflexes  are  among  the  earliest  and  commonest  of  the 
physical  signs  of  paresis.  One  or  both  pupils  are  myotic  and 
do  not  react  to  light,  or  the  consensual  reflex  (wavering  of  the 
pupil  when  light  is  admitted  to  or  excluded  from  the  other  eye) 
is  absent.  Slight  incoordination  and  twitching  of  the  face  and 
tongue  also  occur  early,  and  upon  these  a  probable  or  even  a  cer- 
tain diagnosis  may  be  had  if  they  are  associated  with  the  famil- 
iar moral  irresponsibility,  the  change  of  character  that  makes 
the  paretic  so  dangerous  to  the  community.  The  importance  of 
examining  the  cerebro-spinal  fluid  to  distinguish  paresis  from 
neurasthenia  and  alcoholism  cannot  be  overestimated    (page 

376). 

Prognosis. — Tabes  may  be  controlled  (sometimes  with- 
out antisyphilitic  treatment,  oftener  with  it)  for  an  indefinite 
time,  even  for  many  years.  When  controlled  the  muscular 
incoordination  may  be  lessened  by  systematic  gymnastics. 
The  paralyzed  bladder  may  even  resume  its  functions  spon- 
taneously (one  case)  or  be  improved  by  operation  (two  cases). 
But  the  stigmata  of  lost  knee-jerk,  reflex  iridoplegia,  and  static 
ataxia  do  not  disappear. 

Paresis,  though  it  show  brief  remissions,  can  neither  be  con- 
trolled nor  cured. 

Treatment. — The  treatment  of  either  condition  should 
begin  with  a  short,  sharp  course  of  antisyphilitic  medication 
(page  148).  The  older  authors  depended  chiefly  upon  iodids; 
nowadays  injections  of  mercury  are  often  used  without  iodids. 
I  believe  both  do  good  and  should  be  pushed  to  the  limit  of  tol- 
eration. 

Successive  courses  at  intervals  of  three  to  six  weeks  may 
be  employed  to  push  or  hold  an  advantage  already  gained.  But 
if  the  -first  thorough  trial  of  antisyphilitics  acJiieves  nothing, 
it  should  not  be  repeated.     The  tonic,  hygienic,  educative,  and 


112  THE    COURSE    OF    SYPHILIS 

orthopedic  treatments  may  be  conducted  simultaneously.  They 
concern  the  neurologist,  not  the  syphilologist. 

Syphilitic  Spinal  Paralysis.  — Erb  ^  affirms  that  certain 
cases  of  spastic  paraplegia,  occurring  in  syphilitic  patients,  are 
due  to  syphilis,  though  the  pyramidal  tracts  (lesions  of  which 
cause  spastic  paraplegia)  do  not  show  typically  syphilitic 
lesions.  Hence  the  condition  is  a  parasyphilitic  one.  Erb  has 
entitled  it  syphilitic  spinal  paralysis. 

This  condition  differs  clinically  from  other  types  of  spas- 
tic paraplegia  in  only  a  few  features.  There  is  the  same  slow 
progress  with  years  during  which  the  disease  does  not  advance 
(though  occasionally  the  progress  is  quite  rapid,  the  onset 
acute);  there  is  the  characteristic  symptom  complex;  viz., 
motor  weakness,  chiefly  in  the  lower  extremities,  spastic  rigid- 
ity of  the  lower  extremities,  and  exaggerated  reflexes,  i.  e., 
Babinski  reflex,  ankle  clonus,  and  exaggerated  knee-jerk. 

From  this  general  type  the  syphilitic  variety  differs  chiefly 
in  three  ways : 

1.  History  or  signs  of  previous  syphilis. 

2.  Partial  or  complete  bladder  paralysis  (which  is  not  seen 
in  the  non-syphilitic  cases). 

3.  Slight,  early  paresthesia.  The  areas  of  disturbed  sen- 
sation may  be  discovered  only  after  careful  examination. 

1  Deutsche  Zeitschr.  }.  Nervenheilk.,  1902-3,  vol.  xxiii,  p.  347. 


CHAPTER    VIII 
DIAGNOSIS 

The  diagnostic  problem  of  syphilis  is  twofold :  viz.,  Has 
the  patient  syphilis?    Is  the  lesion  syphilitic? 

To  the  victim  the  two  questions  are  one.  If  he  knows  he 
has  syphilis  every  pimple  and  pain  looks  syphilitic  to  him.  But 
the  practitioner  must  be  more  judicious.  If  the  patient  seem 
syphilitic,  but  the  lesion  not  so,  let  him  be  slow  to  infer  a  con- 
nection between  the  two.  If  the  lesion  seem  syphilitic  and  the 
patient  not  so,  let  him  be  even  slower. 

A  few  examples  will  elucidate  the  necessity  for  this  dis- 
tinction. 

Case  XXII. — A  patient,  in  the  thirteenth  year  of  his  syphilis, 
having  had  no  symptom  of  the  disease  for  several  years,  comes 
with  a  small,  scabbed  ulcer  under  the  right  eyebrow.  It  is  super- 
ficial and  nondescript,  and  is  accordingly  watched  for  two  weeks. 
During  this  time  it  increases  slowly  in  size  and  becomes  a  char- 
acteristic little  syphilitic  ulcer.  It  yields  promptly  to  mixed 
treatment. 

Nine  months  later  he  returns  with  a  similar  spot  near  the 
angle  of  his  mouth.  He  insists  on  antisyphilitic  treatment,  and 
it  is  accordingly  administered,  but  the  sore,  instead  of  healing, 
remains  nondescript  for  a  week  or  so.  Then  he  disappears  for  a 
month,  and  returns  (still  vainly  under  treatment)  with  a  typical 
warty  epithelioma.     It  is  scraped,  cauterized,  and  cured. 

Eighteen  months  elapse,  and  he  returns  with  what  looks  like 
a  suppurating  hair  follicle  on  the  nasal  septum  just  where  it  joins 
the  lip.  Under  local  applications  this  improves  for  a  time,  then 
suddenly  begins  to  spread  and  destroy  the  surrounding  tissue. 
This  is  checked  in  a  few  days  and  healed  in  a  month  by  injec- 

"3 


114 


DIAGNOSIS 


tions,  inunctions,  and  iodid  of  potash.    The  septum  is  left  sHghtly 
deflected. 

This  very  striking  example  of  the  caution  requisite  in  diag- 
nosis, even  when  the  patient  is  known  to  be  syphilitic,  requires 
no  further  comment.  Case  III  (page  19)  is  a  sad  instance 
of  neglect  in  this  regard. 

The  opposite  error,  a  mistaken  diagnosis  of  S3^philis  founded 
on  a  single  lesion  which  appears  to  be  syphilitic,  is  wofully 
common.  Every  syphilologist  sees  hundreds  of  patients  who 
have  been  condemned  to  years  of  treatment  and  a  lifetime  of 
terror  by  the  rash  diagnosis  of  syphilis  from  the  appearance 
of  a  genital  sore  (see  page  243).  Another  common  error  is  to 
treat  headache  or  neuralgia  by  iodid  of  potash,  and  then,  noting 
some  fancied  or  fleeting  amelioration,  to  infer  the  existence  of 
syphilis. 

Nothing  could  be  more  unwarranted ;  nothing  more  de- 
structive. For  if  there  is  one  error  worse  than  to  assure  a 
syphilitic  he  is  clean,  it  is  to  assure  a  clean  man  he  is  syphilitic. 


SYPHILOPHOBIA 

The  fear  of  syphilis  is  much  more  acute  in  those  who  only 
think  they  have  the  disease  than  in  those  who  have  its  actual 
manifestations  to  check  the  riot  of  imagination.  The  horrors 
of  syphilis  pale  into  insignificance  compared  with  those  of 
syphilophobia,  as  this  condition  is  called.  It  assumes  every 
variety  of  hysteria  and  neurasthenia.  I  have  known  it  to  drive 
a  man  to  suicide. 

Case  XXIII. — I  have  known  a  woman,  brutally  ill-treated  and 
cast  off  by  her  husband,  to  fancy  she  had  syphilis  and  wander 
from  doctor  to  doctor,  until  one  ill-advised  man,  rather  in  the 
hope  of  relieving  her  mental  condition  than  impressed  by  her 
symptoms,  told  her  she  had  syphilis  and  gave  her  mercury.  She 
hailed  him  as  a  deliverer,  wept  upon  his  shoulder,  tortured  him 


MEANS    OF    DIAGNOSIS    .  I15 

for  a  year  with  every  conceivable  imaginary  symptom,  and  finally 
came  in  triumph  leading  her  beautiful  little  child,  in  whom  she 
declared  she  had  observed  symptoms  of  the  fell  disease. 

Case  XXIV. — I  have  known  a  man  to  marry  and  to  consult 
a  physician  the  following  day  on  account  of  a  sore  which  had 
just  appeared  upon  the  foreskin.  The  doctor,  overlooking  the 
obvious  cause,  pronounced  it  chancre.  The  man  never  saw  his 
wife  again,  obtained  a  divorce,  and  spent  the  rest  of  his  days 
bringing  out  eruptions  with  iodid  of  potash  and  "  driving  them 
in  "  with  mercury.  When  he  came  under  my  treatment,  some 
ten  years  later,  it  was  impossible  to  separate  him  from  his  drugs. 


MEANS   OF   DIAGNOSIS 

To  avoid  such  horrors  with  certainty  we  should  have  an 
infallible  laboratory  reaction  for  syphilis.  But  we  have  it  not. 
We  depend  mainly — in  most  instances  entirely — on  clinical 
evidence. 

The  means  of  diagnosing  syphilis  may  be  classified  as  fol- 
lows : 

1.  Laboratory  Diagnosis. — Examination  for  spirocheta. 

Inoculation  of  monkeys. 
Specific  reaction. 
Examination  of  the  blood. 
Examination   of   syphilitic  tis- 
sue (biopsy). 

2.  Clinical  Diagnosis. — History. 

Scars  of  previous  lesions. 
Appearance  of  the  present  lesion. 
Effect  of  treatment. 

Examination  for  Spirocheta. — The  opinion  of  a  real 

expert  is  valuable  confirmatory  testimony.     But  even  the  most 

expert  may  fail  to  find  the  spirocheta  when  present,  and  may 

think  he  sees  it  when  absent.     Hence  such  evidence  is  only 
10 


Il6  DIAGNOSIS 

confirmatory.  I  find  it  most  useful  in  the  differential  diagno- 
sis of  chancre  and  of  buccal  sores  (pages  243,  249). 

Inoculation  of  Monkeys. — This  can  never  be  generally 
employed  for  lack  of  subjects.     It  appears  to  be  a  reliable  test. 

Specific  Reaction. — The  only  specific  reaction  at  pres- 
ent available  is  the  Justus  test,  the  Wasserman  serum  not  being 
reliable  (page  34). 

Dr.  Justus  asserted  (in  1895)  that  when  a  syphilitic,  un- 
cured,  but  not  under  treatment,  is  given  a  stifif  dose  of  mer- 
cury, preferably  by  injection  or  by  inunction,  his  hemoglobin 
percentage  falls  from  ten  to  twenty  points  in  from  three  hours 
to  one  day.  This  change  he  considered  pathognomonic  of 
syphilis. 

The  question  has  been  well  thrashed  out  ^  with  the  result 
that  this  test  is  found  to  be  fairly  reliable  only  in  the  early 
and  more  active  stages  of  syphilis.  But  as  it  sometimes  gives 
positive  results  in  non-syphilitics,  and  negative  findings  even  in 
actively  syphilitic  cases,  it  is  of  no  clinical  importance.  The 
recognized  blood  changes  of  syphilis  have  no  diagnostic  sig- 
nificance. 

Examination  of  Syphilitic  Tissue. — The  pathological 
changes  described  on  pages  46,  327,  should  be  a  help  in  diagno- 
sis. A  snipping  from  the  lesion  may  help  differentiate  gumma 
from  neoplasm  or  tuberculosis.  Yet  in  practice  this  is  rarely 
employed,  perhaps  because  the  actual  appearance  of  a  specimen 
thus  obtained  is  often  quite  nondescript.  The  pathologic  char- 
acteristics of  syphiloma  are  ill-defined  and  of  a  negative  type, 
and  it  is  often  difficult  to  get  a  deep  enough  section  of  the 
growth  to  show  its  structure. 

In  practice  I  have  known  this  method  to  fail  signally  in 
two  instances.  In  one  it  led  to  the  excision  of  a  chancre  of  the 
lip;  in  the  other  to  repeated  curettage  and  cauterization  of  a 


1  Cf.  Feuerstein,  Arch.  /.  Derm.  u.  Syph.,  1903,  vol.  Ixvi,  p.  363. 


MEANS    OF    DIAGNOSIS  117 

gummatous  ulcer  of  the  nose.  Both  were  mistaken  for  epithe- 
lioma. In  the  diagnosis  of  an  obscure  lingual  or  laryngeal 
growth,  however,  I  have  never  known  biopsy  to  mislead. 

Clinical  Diagnosis. — Whereas  the  application  of  the  labora- 
tory tests  is  as  yet  limited  and  bound  to  conform  with  the 
clinical  findings,  these  latter  are  almost  universally  applicable. 
We  are  therefore  much  better  acquainted  with  the  limitations 
of  our  clinical  tests,  and  in  the  present  state  of  our  art  they  are 
the  more  reliable. 

Yet  there  is  a  sharp  distinction  between  the  method  of 
applying  these  two  classes  of  tests.  The  laboratory  tests  are 
applied  singly ;  the  success  of  one  of  them  is  almost  as  convinc- 
ing as  though  they  all  coincided.  But  the  clinical  tests  must 
be  applied  all  together.  History  and  scars  give  us  a  hint  of 
what  may  he  the  trouble;  this  impression  is  strengthened  or 
weakened  by  the  appearance  of  the  lesion,  and  confirmed  or 
refuted  by  the  effect  of  treatment.  When  all  four  clinical  tests 
agree  we  are  certain  beyond  the  certainty  conferred  by  any 
laboratory  report.  But  if  they  fail  to  agree  we  may  remain  in 
doubt,  and  the  lesion  may  heal  and  leave  us  there.  For  recov- 
ery under  antisyphilitic  treatment  is  no  proof  that  the  lesion 
was  syphilitic  unless  it  was  typically  syphilitic  in  appearance 
or  unless  there  remains  a  typical  syphilitic  scar  (see  Case  XIV, 
page  89). 

Thus  no  one  test  is  absolutely  convincing.  We  must  apply 
them  all.  In  every  instance  we  must  endeavor  to  prove  the 
patient  syphilitic  and  the  lesion  (the  effect  of  treatment)  must 
confirm  our  opinion. 

The  History. — That  the  patient  has  had  a  sore  on  his 
penis  and  has  taken  mercury  is  no  proof  that  he  has  had  syphi- 
lis ;  that  Dr.  X.  is  convinced  should  carry  little  weight ;  that 
the  patient  is  convinced  carries  no  weight  whatever.  The 
penile  sore  may  have  been  herpes,  the  skin  lesions  acne,  the 
mouth  lesions  aphthous,  the  pains  neurotic. 


Ii8  DIAGNOSIS 

Yet  the  ensemble  of  a  syphilitic  history  is  often  quite  con- 
vincing. If  the  sore  was  a  month  coming  out  and  a  short 
while  healing,^  if  the  groin  nodes  were  not  gravely  involved, 
if  the  skin  lesions  were  slight  and  the  mouth  symptoms  severe, 
there  will  be  no  scars,  yet  there  is  a  strong  presumption  of 
syphilis. 

On  the  other  hand,  if  the  patient  speaks  of  great  inguinal 
adenitis,  raves  about  his  diurnal  headache,  bewails  his  senile 
baldness,  and  triumphantly  exhibits  a  glistening  or  congested 
throat,  depressing  his  tongue  with  professional  ability,  fear 
him.     He  is  a  true  syphilophobe. 

The  Scars. — To  confirm  the  impression  derived  from  the 
patient's  history  we  look  for  scars.  The  whole  body  should 
be  inspected,  and  the  patient  may  indicate  some  special  region ; 
but,  generally  speaking,  evidence  of  past  syphilis  will  be  found 
in  the  glands,  the  legs,  the  bones,  the  mouth,  and  the  site  of 
chancre. 

Enlarged  nodes  are  the  exception  rather  than  the  rule  in 
syphilis.  Within  two  weeks  after  the  appearance  of  chancre 
the  typical  inguinal  adenitis  appears,  and  lasts  some  three  to 
six  months.  General  syphilitic  adenitis  (page  260)  usually 
follows  close  upon  the  first  general  eruption,  and  disappears 
well  within  the  year.  Hence  syphilitic  adenitis  is  extremely 
rare  after  the  first  year. 

The  skin  of  the  legs  is  the  usual  site  of  destructive  skin 
lesion,  and  here  we  may  look  to  find  thin,  round,  depressed 
(pigmented)  scars  (page  274)  in  most  severe  or  neglected 
cases. 

The  hones,  especially  the  tibiae,  should  be  carefully  pal- 
pated. The  exostoses  (page  431)  left  by  unsuspected  peri- 
ostitis may  thus  be  discovered. 

The  mouth  sometimes  bears  typical  deformity  of  the  pal- 

iThe  patieftt  considers  the  chancre  healed  when  it  ceases  to  be  eroded. 
The  lump  persisting  many  weeks  thereafter  does  not  concern  him. 


MEANS    OF    DIAGNOSIS  II9 

ate  or  fauces,  though  the  secondary  lesions  of  these  regions, 
however  severe,  vanish  and  leave  no  trace.  But  the  tongue 
should  be  inspected  most  carefully  for  erosions  or  pearl  spots. 
Dr.  N.  B.  Potter  ^  finds  strong  confirmatory  evidence  of  syphi- 
lis in  destruction  of  the  large  papillae  at  the  base  of  the  tongue 
(Virchow's  atrophia  levis).  These  are  palpable  rather  than 
visible.  On  passing  the  finger  over  the  back  of  the  tongue  one 
feels  it  to  be  glazed  and  smooth  instead  of  lumpy,  as  is  the  nor- 
mal tongue.  This  destruction  of  the  large  papillae  by  syphilis 
is  common,  though  by  no  means  constant.  It  may  be  of  assist- 
ance in  diagnosing  syphilis,  but  is  not  an  infallible  sign. 

The  scar  of  the  chancre  may  be  absent  and  is  often  insig- 
nificant. A  thick  round  scar  on  the  skin  of  the  penis  is  sug- 
gestive of  chancre ;  but  if  the  scars  are  multiple  or  if  there  are 
scars  in  the  groin  the  lesion  v^as  probably  chancroid.  Scars 
w^ithin  the  prepuce,  even  if  single,  usually  mean  chancroid. 

The  Active  Lesion. — The  diagnosis  of  the  various  lesions 
of  syphilis  w^ill  interest  us  as  v^e  take  them  up  in  turn. 

The  Effect  of  Treatment. — Having  decided  that  the 
lesion  is  syphilitic  we  turn  to  treatment  both  for  cure  and  for 
confirmation  of  the  diagnosis.  Indeed,  one  all  too  often  finds 
it  impossible  to  make  an  accurate  diagnosis  without  the  test 
of  treatment  (page  205).  The  history  may  be  vague,  scars 
lacking,  the  lesion  itself  atypical,  and  biopsy  impracticable. 
We  then  administer  iodids  and  mercury,  and  judge  from  the 
result  whether  the  lesion  be  syphilitic. 

No  patient  should  be  put  to  this  test  of  treatment  without 
due  deliberation  as  to  its  effects  upon  mind  as  well  as  body. 
If  the  lesion  itself  is  benign,  the  syphilis  ancient,  and  the 
patient  neurotic,  it  is  wiser  to  wait  a  bit  and  try  such  other 
methods  of  cure  as  may  suggest  themselves,  until  the  failure 
of  these  strengthens  the  probability  of  syphilis.     For  unless 

>  Boston  Med.  and  Surg.  J.,  1906,  March  8. 


I20  DIAGNOSIS 

there  is  a  moral  certainty  of  syphilis,  or  unless  the  lesion  is 
destructive  or  threatening,  the  shock  to  the  patient's  nervous 
system  from  the  suggestion  that  his  syphilis  has  relapsed  may 
not  be  incurred  lightly.  He  must  be  protected  from  his  own 
fears  as  far  as  possible. 

DIAGNOSIS    OF    DIFFERENT   PERIODS   OF   THE   DISEASE 

We  may  summarize  here  certain  diagnostic  situations  that 
constantly  come  up. 

The  Initial  Stage. — To  diagnose  syphilis  by  the  appear- 
ance of  a  chancre  one  must  find  (page  242) 

1.  Typical  chancre, 

2.  Typical  regional  adenitis, 

3.  Negative  autoinoculation,  and 

4.  Spirocheta  pallida. 

The  Secondary  Outbreak. — Various  combinations  of  cir- 
cumstances lead  to  a  diagnosis  at  the  time  of  the  secondary  out- 
break.    The  most  common  combinations  are  the  following : 

1.  General  macular  or  papular  eruption  with  the  scar  of 
chancre  and  persistent  regional  adenitis. 

2.  Scattered  syphilitic  papules  with  the  chancre  and  lym- 
phatic nodes. 

3.  Chancre  and  lymphatic  nodes  undiscoverable ;  general 
macular  or  papular  eruption  combined  either  with  scabs  in  the 
scalp  or  mucous  papules  in  the  mouth,  or  symptoms  of  gen- 
eral toxemia  (notably  nocturnal  pains). 

4.  Mouth  lesions  combined  either  with  scabs  in  the  scalp 
or  characteristic  general  adenopathy.. 

5.  Preemptive  fever  with  toxic  symptoms,  scar  of  chan- 
cre, and  persistent  nodes. 

In  a  Period  of  Cahn. — Within  the  first  six  months  typical, 
posterior  cervical,  and  epitrochlear  adenopathy  are  usually 
found.     If  both  sets  of  nodes  are  enlarged  and  the  patient's 


DIFFERENTIAL    DIAGNOSIS  121 

history  is  suggestive  of  syphilis,  it  is  proper  to  confirm  the 
diagnosis,  since  the  chances  are  that  the  patient  has  the  disease, 
and  it  is.  therefore,  safer  for  him  to  continue  treatment  than 
to  stop  it. 

After  the  first  six  months  there  is  often  no  trace  whatever 
of  the  disease.  In  this  event  we  must  depend  entirely  upon 
the  history,  and,  even  though  it  be  not  very  impressive,  it  is 
usually  wiser  to  continue  the  treatment  on  the  diagnosis  pre- 
viously given ;  for  there  is  no  means  of  proving  that  the  patient 
has  not  syphilis,  and  the  omission  of  treatment  may  bring  him 
grave  relapses  in  the  future. 

Later  Relapses. — The  diagnosis  rests  chiefly  upon  the 
characteristics  of  the  lesion  and  its  reaction  to  appropriate 
treatment.  But,  as  already  stated,  the  patient's  history  should 
be  searched  and  his  body  carefully  inspected. 

Tertiary  lesions  of  brain,  bone,  and  viscera  quite  often  occur 
in  patients  who  give  no  history  of  previous  syphilis  and  show 
no  scars.  In  such  cases  we  must,  therefore,  go  by  the  physical 
characteristics  of  the  lesion.  Yet  the  treatment  instituted  must 
always  be  regarded  as  tentative  until  the  resolution  of  the 
lesion  proves  that  it  is  syphilitic.  The  dangers  of  overtreat- 
ment,  especially  in  obscure  lesions  of  the  nervous  system  which 
may  or  may  not  be  syphilitic,  must  always  be  borne  in  mind 
(page  148). 

DIFFERENTIAL  DIAGNOSIS 

Syphilis  simulates  almost  every  disease.  Any  one  of  its 
graver  lesions  may  be  confused  with  cancer  or  tuberculosis. 
The  early  secondary  fever,  as  well  as  the  less  easily  recognized 
late  tertiary  fever  (page  269),  simulates  malaria,  typhoid, 
tuberculosis,  and  sepsis.  Genital  chancre  may  be  almost  indis- 
tinguishable from  chancroid,  buccal  chancres  from  Vincent's 
angina.  Cerebral  and  cerebro-spinal  syphilis  reproduce  the 
clinical  picture  of  epilepsy,  apoplexy,  brain  tumor,  paresis,  and 


122  DIAGNOSIS 

tabes.  Skin  syphilis  counterfeits  eczema,  psoriasis,  and  lichen 
planus.  But  syphilis  as  a  whole  simulates  only  one  disease : 
viz.,  yaws. 

Yaws  {froMhoesia  tropica)  is  so  closely  allied  to  syphilis 
that  Hutchinson  has  alleged  them  to  be  identical. 

The  striking  points  of  similarity  in  the  two  diseases  are  the 
following:  The  most  obvious  lesions  of  each  are  in  the  skin; 
these  skin  lesions  are  circinate  in  character  and  are  frequently 
clustered  about  the  mucous  orifices;  the  pains  caused  by  each 
disease  are  much  more  marked  at  night;  the  cure  in  each  is 
effected  mainly  by  mercury  and  iodid  of  potash.  A  spirocheta 
as  nearly  as  possible  identical  with  S.  pallida  has  been  identi- 
fied by  Castellani  ^  and  Wellman  in  the  lesions  of  yaws. 

But  the  differences  between  the  two  diseases  are  no  less 
striking.  "  Yaws  is  a  chronic,  highly  contagious  disease,  con- 
fined to  certain  tropical  countries,  and  characterized  by  a  pecul- 
iar cutaneous  eruption  which  goes  through  the  stages  of 
squamae,  papules,  and  tubercles  " — these  tubercles  split,  and 
a  granulating  mass  pushes  through  them — "  it  is  accompa- 
nied by  a  variable  (but  generally  slight)  amount  of  constitu- 
tional disturbance  and  tends  to  recovery"   (Scott). 

The  contrasting  characteristics  of  yaws  and  syphilis  may 
be  tabulated  as  follows  :  ^ 

SYPHILIS  YAWS 

Pandemic  Coniined  to  the  tropics 

Transmissible  by  heredity.  Never  inherited. 

Primary    sore    constant    and      Primary  sore  inconstant  and 
pathognomonic.  no     different     from     other 

skin  lesions. 
Reinfection  extremely  rare.  Re-infection  not  uncommon. 

^Brit.  M.  J.,  1905,  vol.  ii,  p.  1330;   /.  of  Trop.  M.,  1906,  vol.  ix,  p.  1. 
^This  table  is  founded  on  that  of  Jaenseline,  Brit.  M.  J.,  1905,  vol.  ii,  p. 
1276. 


DIFFERENTIAL    DIAGNOSIS 


123 


SYPHILIS 

Pandemic 
Autoinoculation  impossible. 

Eruptions  polymorphic. 

Tertiary  syphilid  leaves  typi- 
cal scars. 

Lesions  primary,  secondary, 
and  tertiary. 

Involves  the  mucous  mem- 
branes and  viscera. 

No  itching. 

Loss  of  hair. 

Confers  no  immunity  against 
yaws. 


YAWS 

Confined  to  the  tropics 

Autoinoculation    possible    for 

a  long  time. 
Only  one  type  of  eruption. 
No  scars  unless  irritated. 

No  such  distinction. 

Affects  only  the  skin. 

Itches. 

No  loss  of  hair. 
Confers  no  immunity  against 
syphilis. 


The  fact  that  the  patient  suffering  from  either  disease  may 
be  infected  with  the  other  is  the  best  evidence  that  they  are 
not  related. 


CHAPTER    IX 
PROGNOSIS 

The  general  prognosis  of  syphilis  is  a  gloomy  prospect 
compounded  of  various  follies  amid  which  madness  for  drink 
and  carelessness  in  treatment  stand  preeminent.  All  the 
cases  cited  must  be  read  with  this  in  mind;  not  many 
of  them  were  really  well  treated,  not  many  abstained  from 
drink. 

One  is  fully  justified  in  assuring  the  recently  infected  vic- 
tim that  if  he  obey  orders  he  need  expect  no  great  trouble 
after  the  first  year  or  two  of  his  disease,  and  will  even  bear 
the  outward  semblance  of  cleanliness  during  that  time.  Syphi- 
lis is  a  series  of  surprises,  to  be  sure,  but  the  cases  which  I 
have  personally  supervised  from  beginning  to  end  have  been 
singularly  free  from  grave  relapses,^  a  freedom  which  I  be- 
lieve they  owe  to  the  system  of  treatment  followed,  and  con- 
stant insistence  upon  the  fact  that  relapses  can  neither  be  fore- 
seen nor  absolutely  prevented  by  any  system  of  treatment.  If 
the  patient  is  made  to  recognize  that  he  cannot  be  guaranteed 
against  relapse  in  his  own  person  (however  sure  he  may  be 
that  he  is  no  longer  infectious)  he  is — sanely — on  his  guard 
and  prepared  to  report  at  the  outbreak  of  symptoms  when 
they  may  be  promptly  controlled. 

In  short,  a  case  of  syphilis  intelligently  treated  and  prop- 
erly conducted  usually  terminates  with  the  cessation  of  treat- 

1  But  I  have  not  been  able  as  yet  to  follow  a  number  of  them  over  a  sufficient 
length  of  time  to  give  results  of  statistical  value. 
124 


THE    PATIENT'S    CONSTITUTION  125 

ment  at  the  end  of  three  years  in  all  things  except  the  matri- 
monial guarantee  which  is  habitually  to  be  reserved  for  two 
years  longer. 

But  let  us  consider  the  elements  of  the  prognosis  seriatim ; 
they  are : 

1.  The  patient's  constitution. 

2.  His  environment. 

3.  His  habits,  chiefly  as  regards  alcohol  and  tobacco. 

4.  His  treatment. 

5.  The  lapse  of  time. 

THE   PATIENT'S   CONSTITUTION 

We  can  never  assure  a  patient  that  his  syphilis  is  going 
to  be  light.  From  the  duration  of  primary  or  of  secondary 
incubation  no  inference  may  be  drawn  as  to  conditions  six 
months  hence.  And  all  similar  signs  are  worthless  and  mean- 
ingless. Yet,  retrospectively,  one  can  see  that  such  a  patient 
has  had  little  trouble  with  his  disease,  has  perhaps  never  really 
suffered  from  it  at  all;  while  such  another  has  labored  and 
slaved  for  months  and  years  to  keep  himself  clean.  Why  this 
should  be  we  no  more  know  than  why  one  man  dies  of  pneu- 
monia and  another  does  not. 

This  partial,  congenital  immunity  may  even  be  so  great 
as  to  lead  to  a  spontaneous  cure  after  the  appearance  of  the 
chancre.  Incredible  as  this  may  seem — and  I  have  not  seen 
it  myself — it  is  attested  by  excellent  authority.  Yet  the  fact 
may  be  other  than  the  seeming.  The  patient  who  without 
treatment  (or  with  treatment  for  that  matter)  skips  the  early 
secondary  symptoms  is  by  no  means  quit  of  his  disease.  He 
is  just  as  syphilitic,  just  as  much  a  candidate  for  prolonged, 
systematic  treatment  as  his  most  intensely  infected  neighbor 
— witness  the  following  case,  the  only  male  in  which  I  know 
the  early  secondaries  were  skipped : 


126  PROGNOSIS 

Case  XXV. — No  symptoms  or  treatment  for  six  years ;  then 
naso- pharyngeal  ulcerations.  The  patient,  a  thin,  rather  small, 
and  not  very  rugged  man,  aged  twenty-one,  showed  on  January 
30,  1880,  a  healing  sore  upon  the  penis,  which  had  appeared  on 
January  15th,  and  was  attributed  to  coitus  on  December  18,  1879. 
The  sore  had  been  cauterized,  but  when  first  seen  it  was  no 
longer  ulcerated,  though  very  hard  and  sharp  at  the  edge — a 
typical  chancre.  The  glands  in  both  groins  were  large,  not  pain- 
ful, not  very  characteristic.  Judgment  was  withheld  and  the 
patient  closely  watched ;  but  the  induration  disappeared,  and  no 
further  symptom  developed.  No  mercury  or  iodids  were  given. 
During  1881  and  1882  he  was  treated  for  gonorrhea,  but  still 
showed  no  sign  of  syphilis.  He  was  not  seen  again  until  April 
15,  1886.  "  Patient  has  been  perfectly  well.  He  never  had  any 
symptoms  of  syphilis.  He  never  had  another  sore.  He  never 
took  a  particle  of  mercury  or  iodin.  Yet  now  he  has  a  charac- 
teristic thickening  of  the  fauces,  [and]  a  sloughy,  pultaceous 
ulcer,  distinctly  syphilitic.  His  throat  has  troubled  him  for  five 
weeks.  He  has  lost  five  pounds,  and  Dr.  Bosworth  diagnosti- 
cates syphilis  from  the  throat."  There  is  also  an  ulcer  on  the 
floor  of  the  nose. 

Under  mixed  treatment  the  throat  promptly  healed;  he  lost  a 
small  piece  of  the  vomer,  and  in  August  he  was  clean.  Treat- 
ment was  continued  until  October  22,  1888,  no  further  symptoms 
appearing.     He  has  not  been  seen  since. 

The  case  points  its  own  moral :  put  no  faith  in  aborted 
syphilis,  however  mild,  however  readily  relieved;  give  it  the 
benefit  of  a  full  course  of  treatment.  Willingness  to  take 
treatment  is  no  less  devoutly  to  be  desired  than  a  relative 
immunity  from  symptoms.  Indeed,  morally  speaking,  the 
patient  with  grave  or  persistent  early  symptoms  has  the  best 
prospect  of  an  early  cure,  for  his  physical  woes  demonstrate 
the  gravity  of  the  disease  and  the  necessity  of  persistent  treat- 
ment far  better  than  the  most  impressive  lecture.  And  though 
relative,  congenital  immunity  is  surely  the  syphilitic's  most 
valuable  asset,  he  can  never  be  sure  of  its  possession,  while, 
practically  speaking,  good  habits  and  docility  to  treatment  con- 


THE    PATIENT'S    ENVIRONMENT  127 

fer  a  far  more  tangible  assurance  of  future  health  than  any- 
thing else  we  know  of. 

Interaction     with     Other     Diseases     and     Diatheses.— 

But  the  effect  of  the  constitution  of  the  patient  upon  the  course 
of  the  disease  is  by  no  means  limited  to  the  bald  moderation 
or  intensification  of  symptoms.  Syphilis  brings  out  every 
latent  weakness.  It  encourages  the  development  of  tubercu- 
losis. It  plunges  the  hysterical  and  the  neurasthene  into  new 
depths  of  despair.  It  feeds  every  organic  neuropathic  predis- 
position. On  the  other  hand,  the  syphilis  itself  is  colored  by 
every  tinge  of  heredity — diathesis  and  temperament  alike. 
Persons  of  gouty  tendency  run  to  scaly  and  tuberculoid  erup- 
tions, and  are  said  to  be  especially  liable  to  syphilis  of  the 
nervous  system  (though  I  cannot  fully  substantiate  this  last 
assertion).  Eczema  becomes  almost  inextricably  intermingled 
with  eczematoid  syphilids  (Lichen  planus,  psoriasis,  and  sim- 
ilar skin  lesions,  though  they  may  be  closely  simulated  by 
syphilis,  can  scarcely  be  said  to  influence  the  course  of  the 
disease).  The  anemic  or  "scrofulous"  victim  suffers  in- 
tensely from  early  toxemia,  florid,  general  early  skin  lesions, 
and  mucous-membrane  lesions  of  a  most  persistent  relapsing 
character.  The  neuropath  is  stricken  in  his  point  of  least 
resistance.  In  short,  syphilis  assumes  the  habit  of  its  victim. 
Its  course  depicts  his  weakness. 

THE    PATIENT'S   ENVIRONMENT 

Syphilis,  like  character,  is  founded  upon  heredity  modified 
by  environment.  Every' influence  to  which  the  patient  is  sub- 
jected may  react  upon  his  disease.  It  were  vain  to  try  to  enu- 
merate every  shade  of  environment,  but  a  few  of  the  more 
striking  facts  may  be  noted. 

Climate. — The  tropics  have  always  borne  the  evil  reputa- 
tion of  producing  the  vilest  forms  of  venereal  disease.     Yet, 


128  PROGNOSIS 

as  already  noted,  the  source  of  syphilis  has  no  influence  upon 
its  prognosis.  If  syphilis  is  most  virulent  in  the  tropics  this 
is  doubtless  due  to  the  debilitating  efifects  of  climate,  or  ma- 
laria, and  to  the  carelessness  or  indolence  of  the  sufferer. 

Age. — The  age  at  which  syphilis  is  contracted  seems  to 
have  some  effect  upon  its  course.  The  overwhelming  charac- 
ter of  hereditary  or  infantile  syphilis  is  too  well  known  to  re- 
quire demonstration.  Yet  after  puberty  age  is  not  a  very 
strong  factor.  To  be  sure,  the  average  patient  infected  after 
thirty  seems  to  develop  tertiary  lesions  rather  more  quickly 
than  does  he  who  is  infected  before  that  age ;  but  he  is  through 
with  them  sooner,  too.  And  the  assertion  so  constantly  made, 
and  supported  by  such  general  acceptance,  that  syphilis  ac- 
quired in  old  age  is  most  virulent,  depends,  in  some  instances 
at  least,  upon  the  fact  that  the  old  man  who  acquires  syphilis 
is  likely  to  be  far  more  completely  saturated  with  alcohol  and 
debilitated  by  riotous  living  than  the  younger  victim.  From 
my  cases  I  am  certainly  not  warranted  in  inferring  any  essen- 
tial evil  effect  of  age. 

Debility  and  Trauma.— Mechanical  trauma  occasionally 
induces  a  relapse  of  tertiary  symptoms  (page  38),  but  strik- 
ing instances  of  this  are  not  common.  On  the  other  hand, 
trauma  in  the  widest  sense  is  one  of  the  commonest  of  all 
causes  of  tertiary  relapse.  I  have  now  under  treatment  a 
gumma  of  the  tibia  due  to  a  bruise  and  a  syphilitic  hemiplegia 
occurring  in  a  public  accountant  at  a  time  when  he  was  very 
run  down  by  overwork.  The  hemiplegia  is  doubtless  quite  as 
directly  referable  to  intellectual  strain  as  is  the  gumma  to  con- 
tusion. Indeed,  close  investigation  will  reveal  some  such  ex- 
citing cause  for  a  surprisingly  large  proportion  of  relapses. 
Any  disease,  excess,  or  other  debilitating  influence  weakens 
the  patient's  powers  of  resistance,  and  so  indirectly  permits 
the  relighting  of  a  smoldering  syphilis  much  more  frequently, 
though  not  quite  so  obviously,  as  a  blow  may  excite  a  gumma. 


THE    PATIENT'S    HABITS  129 

THE   PATIENT'S   HABITS 

Since  the  patient's  native  immunity  to  syphilis  is  his  most 
important  asset,  to  fortify  that  immunity  should  be  his  con- 
stant effort.  During  the  first  years  of  the  disease  he  should 
keep  "  in  training."  Regular  hours,  simple  food,  plenty  of 
sleep,  fresh  air^  and  exercise  should  be  his  rule  of  life  in  so  far 
as  his  position  permits.  A  regard  for  the  elementary  rules 
of  hygiene  is  always  helpful,  and  is  in  some  cases  of  syphilis 
as  important  as  in  tuberculosis.  Unfortunately,  the  majority 
of  syphilitics  may  grossly  neglect  the  rules  of  hygiene,  and 
yet  come  to  no  immediate,  manifest  harm.  Consequently  they 
treat  lightly  the  warning  that  bids  them  look  to  a  more  or  less 
distant  and  problematical  future;  they  neglect  to  make  every 
effort  to  stamp  out  the  disease  while  it  is  yet  young,  and  in 
later  years  they  return  groaning  under  afflictions  that  were 
quite  preventable. 

Alcohol. — The  reaction  of  alcohol  upon  syphilis  epitomizes 
the  effects  of  bad  environment  and  evil  habits.  Alcohol  is  the 
commonest  as  well  as  the  most  active  enemy  of  the  syphilitic. 
Malignant  early  syphilis  is  most  frequent  among  those  who  have 
been  alcoholic,  malignant  late  syphilis  among  those  who  remain 
alcoholic.  These  two  are  the  current  causes  of  syphilis  of  the 
nervous  system,  and  the  various  visceral  and  vascular  fibroses. 

In  debating  the  effect  of  alcoholism  in  syphilis  a  strict 
definition  of  the  term  is  essential.  By  alcoholism  is  meant 
chronic  intoxication  by  alcohol.  This  does  not  imply  drunk- 
enness. A  man  may  die  of  alcoholism  without  ever  being 
drunk.  Indeed,  the  man  who  boasts  that  he  cannot  get  drunk 
has  the  opportunity  of  becoming  far  more  alcoholic  than  he 
who  is  laid  low  by  a  stein  of  beer;  and  it  is  precisely  among 
these  hardy  and  incessant  drinkers  that  the  most  pronounced 
evil  effects  may  be  looked  for.  Persistent  drinking  may  make 
it  impossible  to  prevent  or  to  cure  tertiary  relapses.     I  have 


130 


PROGNOSIS 


recently  witnessed  the  most  striking  evidence  of  this  in  a  young- 
man  with  a  tuberculo-ulcerative  infiltration  of  the  lips.  The 
lesions  lasted,  now  better,  now  worse,  for  almost  two  years, 
and  almost  every  exacerbation  could  be  traced  to  a  few,  a 
very  few,  drinks.  Close  questioning  reveals  similar  instances 
quite  frequently. 

But  the  essential  evil  of  alcoholism  is  not  that  it  so  often 
makes  the  early  lesions  of  syphilis  virulent  and  hard  to  cure, 
but  that  it,  combined  with  inefficient  treatment  (and  the  two 
go  hand  in  hand),  is  almost  the  whole  cause  of  late  syphilis. 
I  have  already  cited  my  personal  statistics  in  this  regard,  and 
my  clinical  impression  is  even  stronger — much  stronger — than 
my  statistics. 

On  the  other  hand,  even  in  its  relation  to  alcohol,  syphilis 
plays  strange  freaks.  One  of  my  patients  died  of  drink  in  the 
thirteenth  year  of  his  disease,  having  had  no  symptom  since 
the  early  secondary  outbreak;  another  died  drunk  in  the 
twenty-fourth  year  of  his  disease  and  twelve  years  after  his 
last  symptom  (ulcer,  scaly  palms)  ;  still  another  took  treat- 
ment faithfully,  yet  drank  equally  faithfully.  He  had  a  very 
light  roseola  and  absolutely  nothing  else.  Yet  after  four  years 
he  developed  various  ocular  paralyses,  requiring  the  most  vig- 
orous treatment  for  their  relief.  Thus  the  alcoholic  may  run 
any  conceivable  course;  yet  statistics  show  that  he  is  not  a 
good  risk  if  he  drinks  constantly — even  a  little  (page  103). 

Tobacco. — The  ill  effect  of  tobacco  is  immediate,  local, 
and  obvious.  If  it  excites  mouth  lesions  it  must  be  stopped, 
but  otherwise  it  may  be  used  in  moderation.  Excessive  smok- 
ing must  always  be  prohibited,  for  the  more  a  man  smokes 
the  more  liable  he  is  to  mouth  lesions;  and  since  it  is  pre- 
cisely the  excessive  smoker  who  cannot  be  persuaded  under 
any  circumstances  to  give  up  his  habit  altogether,  he  is  the 
man  of  all  others  who  should  avoid  getting  into  a  condition 
where  he  ought  to  stop.     I  try  to  keep  all  my  patients  down 


THE    LAPSE    OF   TIME  131 

to  two  or  three  cigars  a  day;  but  alas!  I  often  fail,  for  it  is 
harder  to  stop  smoking  than  to  stop  drinking.  Yet  only  the 
other  day  I  saw  a  man  who  said  he  had  smoked  from  six 
to  ten  cigars  a  day  for  twelve  years  following  his  chancre, 
and  the  disease  had  never  relapsed  in  the  month  or  anywhere 
else ;  to  prohibit  such  a  man  from  smoking  would  be  ridiculous. 

THE   EFFECT    OF   TREATMENT 

What  is  the  effect  of  treatment?  In  other  words,  Does 
treatment  cure  syphilis?  There  are  good  reasons  for  doubt- 
ing it.  No  treatment  gives  an  absolute  guarantee  against  re- 
lapse. Exceptionally,  a  case  does  badly  in  spite  of  the  most 
energetic  and  intelligent  treatment.  Impressed  by,  these  iso- 
lated and  exceptional'  facts,  the  pessimist  cries  "  Syphilis  can 
never  be  cured !  "  As  well  say  malaria  can  never  be  cured. 
It,  too,  may  relapse  after  years  of  apparent  health.  It,  too, 
may  prove  malignant  and  intractable.  Yet  what  could  be 
more  essentially  curable  than  the  ordinary  attack  of  chills  and 
fever?  The  same  rule  holds  good  for  syphilis.  The  ordinary 
case  is  perfectly  amenable  to  and  curable  by  treatment.  The 
exceptional  case  is  refractory. 

But  the  distribution  of  yellow  tablets  does  not  constitute 
the  treatment  of  syphilis.  The  art  of  curing  syphilis  is  like 
the  art  of  killing  salmon.  The  skill  of  the  fisherman  and  the 
wiles  of  the  fish  are  quite  as  important  elements  in  the  game 
as  the  strength  of  the  tackle.  Some  fish  are  child's  play; 
others  tax  the  most  experienced  wrist.  And  the  joy — but 
that  is  another  story.  ' 

THE   LAPSE   OF   TIME 

Time  and  treatment  are  the  enemies  of  syphilis.  Age  cer- 
tainly does  wither  her  though  time  cannot  be  said  to  stale  her 

infinite  variety.     If  the  disease  relapses  appropriate  treatment 
11 


132 


PROGNOSIS 


diminishes  by  fully  eighty  per  cent  the  prospect  of  further  re- 
lapse, though  under  this,  as  under  any  other  geometric  pro- 
gression, an  infinite  number  of  relapses  is  possible. 

And,  be  it  noted,  syphilis  does  not  necessarily  shorten  life. 
Because  a  man  has  syphilis  his  days  are  not  lessened.  Scarred 
he  ma)^  be ;  but  unless  he  be  careless  in  his  habits  or  unless  he 
be  the  one  marked  for  destruction  in  spite  of  all  that  man 
can  do  to  aid  him,  his  life  will  be  spared. 

Destructive  visceral  syphilis,  amyloid  disease  from  pro- 
longed toxemia,  the  riddling  of  bone  and  brain  and  skin  with 
a  thousand  lesions — these  horrors  of  the  ancients  are  all  but 
inexcusable  at  the  present  day.  Cerebro-spinal  syphilis,  pare- 
sis, and  aneurysm  still  claim  their  victims,  and  so  does  tabes, 
though  so  brilliant  have  been  the  results  which  I  have  seen  from 
vigorous  antisyphilitic  treatment  in  incipient  (syphilitic)  tabes 
that  I  must  confess  a  great  optimism  in  regard  to  that  malady. 

My  own  statistics  give  no  clew  to  the  active  death-rate 
of  syphihs,  but  the  insurance  statistics  quoted  below  place 
that  as  accurately  as  possible;  though  I  confess  they  impress 
me  as  unduly  pessimistic. 

I  have  studied  2,300  cases  in  regard  to  the  average  dura- 
tion of  the  disease  without  reference  to  sex,  age,  treatment, 
or  habits.     The  findings  are  expressed  in  the  following  table: 

DURATION    OF    2.3OO    CASES 

3  years  or  less 1,511  cases 

4  " 102     " 

5  "     83    " 

6  to  10  years 298     " 

II  "   15 
16  "  20 


21  "  25 

26  "  30 

31  "  35 

36  "  40 


162 
60 

43 

3° 

5 

5 


43  years i  case 


LIFE-INSURANCE    ESTIMATES 


133 


Thus  3  out  of  4  cases  of  syphilis,  as  we  encounter  it  clin- 
ically, end  within  five  years ;  7  out  of  8  within  ten  years ;  while 
only  I  in  30  lasts  over  twenty  years. 

That  these  inferences  are  fairly  accurate  is  proven,  I  be- 
lieve, by  the  following  table,  showing  the  duration  of  the  dis- 
ease in  cases  watched  five,  ten,  and  fifteen  years  since  the  dis- 
appearance of  the  last  symptom.  The  numbers  are  far  fewer, 
but  the  proportions  remain  the  same : 


Watched 

5  Years 

10  Years 

15  Years 

Duration    5  years  or  less 

155 

30 

18 

8 

2 

75 

13 

10 

2 

I 

36 
5 
4 
2 

"          6  to  10  years 

"         II  "    IC     "      

16  "  20     "     

"        21  "  22     "     

I 

Total  number  of  cases 

213 

lOI 

48 

LIFE-INSURANCE   ESTIMATES  1 

In  recent  years  the  influence  of  syphilis  on  mortality  from 
a  life-insurance  standpoint  has  been  discussed  frequently  by 
the  medical  directors  of  life-insurance  companies,  and  at  a  re- 
cent International  Congress  of  Life  Insurance  Medical  Direct- 
ors, at  Berlin,  as  many  as  five  original  papers  on  the  subject 
were  presented.  One  of  these,  by  Dr.  Blaschko,  is  replete 
with  statistics  as  to  the  prevalence  of  syphilis  in  some  of  the 
European  companies,  comparing  urban  and  rural  districts, 
classes  of  the  population,  occupations,  etc.,  etc.,  and  illustrating 
its  influence  as  a  cause  for  morbidity  as  well  as  mortality.  But 
Dr.  Blaschko  also  shows  how  greatly  these  statistics  vary — 
how  untrustworthy  and  useless  they  are  as  a  guide  to  deter- 
mine the  assurability  of  this  class  of  risks.     The  reason  for 


» Communicated  by  Dr.  W.  M.  Bross. 


134  PROGNOSIS 

this  is  that  the  main  effort  of  these  statistics  is  directed  to 
broaden  our  scientific  knowledge  of  syphiHs  in  general,  to  de- 
termine the  importance  of  syphilis  as  a  cause  of  illness  and 
death,  while  for  the  life-insurance  medical  directors  it  is  of 
main  importance  to  determine  the  influence  of  syphilis  on  the 
duration  of  life.  In  view  of  the  deficiency  of  these  statistics 
from  the  insurance  man's  standpoint.  Dr.  Blaschko  was  greatly 
pleased  to  be  able  to  refer  to  the  report  of  Dr.  Tiselius,  pre- 
sented at  the  Sixth  Scandinavian  Life  Insurance  Congress, 
"  an  excellent  report,"  as  Dr.  Blaschko  puts  it,  and  "  of  great 
importance,  because  it  is  the  first  statistical  work  on  this  sub- 
ject compiled  on  a  basis  which  is  entirely  flawless."  This  re- 
port, which  contains  the  experience  of  Scandinavian  compa- 
nies with  policy  holders  who  had  had  syphilis,  gives,  among 
other  information,  that  which  is  most  essential  for  our  work 
— the  number  of  expected  deaths  on  the  basis  of  standard 
mortality  tables  and  the  number  of  actual  deaths  in  the  class. 
The  Scandinavian  campanies  had  an  actual  loss  of  128.5 
deaths  for  every  100  deaths  expected  by  the  17  English 
offices  tables. 

Dr.  Blaschko  did  not  refer  to  the  experience  of  the  Actu- 
arial Society  of  America.  They  found  that  a  history  of  syphi- 
lis gave  a  mortality  of  one  hundred  and  thirty-three  per  cent, 
a  result  which  coincides  closely  with  the  experience  of  the 
Scandinavian  companies.  These  two  reports,  the  one  of  the 
Actuarial  Society  and  the  other  by  the  Scandinavian  com- 
panies, contained  the  only  trustworthy  information  as  to  the 
influence  of  syphilis  on  longevity  which  we  had  until  very 
recently,  when  the  Gotha  Insurance  Company  published  its 
own  experience  with  syphilitic  risks.  This  report  is  con- 
tained in  the  paper  read  by  Dr.  Gollmer  at  the  Berlin  Con- 
gress. It  contains  not  only  a  statement  of  the  Gotha's  ex- 
pected and  actual  losses,  but  also  highly  interesting  tables, 
showing  the  influence  of  syphilis  on  causes  of  death.     I  quote 


LIFE-INSURANCE    ESTIMATES 


135 


here  the  most  important  results  of  this  investigation,  and  also 
those  of  the  American  and  Scandinavian  companies : 


Scandinavian  Companies 

American  Companies 

Goth  A 

Ages  of 
Observation 

Mortality 

Ages  of 
Observation 

Mortality 

Ages  of 
Observation 

Mortality 

20-30 

30-40.... 

AO-50 

50-60 

60-70 

70-80 

Per  cent 
102.8 
106.7 
143-3 
14I-3 
132.4 
100. 0 

15-28 

29-42 

43-56-.-. 

57-70-... 

Per  cent 
105 
134 

153 
102 

15-35---- 
36-50- -  -  - 
51-70.... 
71-90 

Per  cent 
138 
186 
161 
140 

20-80 

128.5 

15-70. . . . 

^33 

15-90 

168 

These  three  experiences  deal  with  material  of  considerable 
size.  The  Scandinavian  experience  comprises  848  deaths; 
the  American,  397  deaths ;  the  Gotha,  487  deaths.  They  show- 
uniformly  a  considerable  excess  mortality,  the  highest  occur- 
ring between  the  ages  of  forty  and  fifty.  The  American  and 
the  Scandinavian  companies  give  results  that  are  very  nearly 
alike;  the  Gotha's  experience  is  decidedly  the  most  unfavor- 
able. The  experience  of  the  American  companies,  and  also  of 
the  Gotha,  tend  to  show  that  the  excessive  death-rate  persists 
through  the  entire  life,  independent  of  the  time  elapsed  since 
infection.  To  some  extent  this  fact  may  be  deduced  from  the 
above  table,  but  it  becomes  more  clearly  apparent  from  the 
following- : 


Insurance 
Years  i  to  5 

Insurance 
Years  6  to  30 

All  Years 

American  companies'  mortality 

Per  cent 
121. 4 

143-5 

Per  cent 
142.3 
172.4 

Per  cent 

^33-3 
168  6 

Gotha 

Even  as  long  as  thirty  years  after  infection  the  mortality 
continued  to  be  fifty  per  cent  in  excess  of  the  normal. 


136 


PROGNOSIS 


GOTHA    MORTALITY    BY    YEARS    ELAPSED    SINCE    INFECTION 


5-  9  years 

10-19  

20-29       "      

30  years  and  over 


Entrants 


55° 
5,899 
5,915 
3,134 


Expected 
Deaths 


3-74 

52-93 

87.92 

112.74 


Actual 
Deaths 


6 
106 
140 
169 


Per  Cent 


200 
159 
150 


The  Gotha  also  gives  us  a  highly  interesting  table  of 
causes  of  death  among  those  who  were  infected  with  syphilis, 
and  compares  the  deaths  occurring  in  this  class  with  those  of 
all  its  policy  holders  who  insured  their  lives  between  the  years 
1852  and  1895  : 


Caiises  of  Death  1 


Infectious  diseases 

Tuberculosis 

Cancers 

Diseases  of  the  metabolic  process. 

Alcoholism „ 

Progressive  paralysis  of  the  brain. 

Disease  of  the  spinal  marrow 

Disease  of  the  respiratory  organs. 

Cerebral  apoplexy,  aneurysm 

Cerebral  apoplexy  alone 

Aneurism  alone 

Disease  of  the  kidneys 

Disease  of  stomach  and  intestines 

Disease  of  the  liver 

Accidents 

Suicides 

Old  age 

Other  diseases 

All  causes 


Expected 
Deaths 


20.00 

51-72 

29-32 

8.61 


12-53 
3-45 
27-23 
70.24 
19.30 
1. 91 
12.77 

11-45 
8.68 

7-39 
9.90 
1. 10 
6.67 


290 . 04 


Actual 

Deaths 

Syphilitic 

Lives 


22 
25 
47 
8 
22 
63 
23 
27 
152 
44 

13 
21 
21 

9 
II 
22 

3 
II 


487 


Mortality 
Per  Cent 


no 

48 

160 

245 
503 
667 

99 
216 

228 

164 


168 


1  The  list  contains  several  duplicates  so  that  the  totals  do  not  sum  up  accu- 
rately. 


LIFE-INSURANCE    ESTIMATES 


137 


Causes  of  Death 


Expected 
Deaths 


ISIental  diseases, 

Paralysis  of  the  brain, 

Other  brain  diseases, 

Spinal  diseases, 

Alcoholism, 

Suicide, 

Circulatory  diseases,  inclusive  of  cerebral 

apoplexy,  and  kidney  diseases 
All  other  causes 


All  causes. 


34.86 


83.01 
172.17 


Actual 
Deaths 


180 


173 
184 


290.04 


487 


Mortality 
Per  Cent 


373 


208 
107 


168 


My  personal  experience  consists  of  1,658  cases,  and  an 
analysis  among  these  shows  a  syphilitic  mortality  of  one  hun- 
dred and  forty-five  per  cent.  The  causes  of  death  run  so 
close  to  the  above  table  that  I  think  it  unnecessary  to  mention 
them  in  detail.  Among  the  number  who  have  been  rejected 
for  life  insurance  because  of  syphilis,  we  found  the  mortality 
to  have  been  166.2  per  cent.^ 

From  the  few  facts  given  above,  I  think  the  conclusion  is 
justified  that  syphilitics  may  be  insured  at  any  time  after  the 
symptoms  have  ceased  to  show  themselves,  but  not  at  standard 
rates.  Syphilis  no  doubt  shortens  the  expectancy  of  life,  and 
there  is  a  largely  increased  mortality  among  the  class  during 
life.  Much  could  be  learned  regarding  this  subject  if  the  life- 
insurance  companies  of  America  would  cooperate  for  a  joint 
investigation  conducted  on  a  uniform  basis. 

Regarding  the  treatment,  it  can  be  safely  assumed  that 
those  who  are  well  enough  off  to  assure  their  lives,  are,  in  the 
vast  majority  of  cases,  treated  to  the  best  of  the  ability  of  the 
medical  man  employed.  ■  The  indications  are,  however,  that  a 
syphilitic  should  always  remain  under  the  observation  of  a 
competent  medical  man. 


»This  percentage  doubtless  represents  an  exceptionally  large  number  of 
neglected  syphilitics  (Keyes,  Jr.). 


CHAPTER    X 

PRINCIPLES  OF   THE   TREATMENT  OF  SYPHILIS 

PREVENTION 

Prophylaxis. — The  prophylaxis  of  syphihs  has  been  dis- 
cussed in  Chapter  I. 

Abortive  Treatment. — To  abort  syphilis  is  impossible. 
Syphilis  may  abort  itself;  but  even  though  no  symptoms  fol- 
lov^  a  true  chancre  we  have  no  means  of  judging  whether  the 
disease  is  ended  or  whether  we  may  look  for  an  outbreak  five 
or  ten  years  hence.  Excision  of  the  chancre  does  not  abort 
syphilis,  clinically  or  experim.entally,  in  man  or  in  monkey. 
Indeed,  Metchnikofif  and  Roux  have  shown  that  excision  of 
the  site  of  inoculation  after  twenty-four  hours  does  not  pre- 
vent the  development  weeks  later  of  true  chancre  or  true  syphi- 
lis. They  have  prevented  the  development  of  syphilis  by  the 
application  of  mercurial  ointment  within  eight  hours  of  inocu- 
lation, but  this  is  the  only  abortive  treatment  they  have  found 
of  any  service.  Hence,  if  the  patient  is  seen  within  tzvelve 
hours  of  a  suspected  contact,  mercurial  ointment  should  he  well 
rubbed  into  the  suspected  part.  After  twenty-four  hours  the 
ointment  may.  be  removed. 

Beyond  this  nothing — neither  cauterization,  nor  excision, 
nor  internal  medication  will  abort  syphilis. 

GENERAL   PRINCIPLES   OF   TREATMENT 

In  the  treatment  of  syphilis  the  physician  has  tzvo  ends  in 
view :  viz.,  to  prevent  the  appearance  of  symptoms  and  to  cure 
138 


THE    ROUTINE    TREATMENT  139 

them  when  they  do  appear — to  control  the  disease  and  to  cure 
its  lesions. 

These  tzvo  ends  are  entirely  distinct,  and  unless  this  dis- 
tinction is  kept  constantly  in  mind  a  discussion  of  the  treat- 
ment of  syphilis  becomes  a  mere  muddle. 

For  example :  It  is  routine  practice  to  administer  mercury 
without  potassium  iodid  during  the  first  year  of  syphilis.  But 
if  the  patient  develops  a  gumma  during  that  first  year,  we 
promptly  administer  iodid,  at  the  same  time  continuing  the 
routine  mercurial  treatment.  We  are  attacking  the  disease  by 
mercury,  the  lesion  by  iodid. 

Again,  suppose  in  the  course  of  the  first  year  of  syphilis 
there  appears  an  obstinate  squamous  syphilid.  The  routine 
treatment  fails  to  control,  and  we  have  recourse  to  more  force- 
ful measures,  to  higher  doses  or  a  more  active  method  (e.  g., 
injections)  of  administering  mercury.  These  we  employ 
solely  on  account  of  the  lesion,  and  having  cured  this  we  drop 
back  to  our  routine  treatment. 

But  if  the  lesion  persists  in  relapsing,  then  we  change 
our  routine  treatment  of  the  disease  in  some  way,  in  order 
to  check  this  tendency,  to  prevent  the  outbreak  of  further 
symptoms. 

Thus  there  are  two  treatments  of  syphilis,  the  one,  routine 
to  prevent  relapse  and  control  the  disease,  the  other,  symp- 
tomatic, to  cure  lesions. 

THE  ROUTINE   TREATMENT 

The  routine  treatment  of  syphilis  is  hygienic,  tonic,  and 
specific.  The  specifics  are  often  ineffective  unless  aided  by  the 
others.  No  one  of  them  may  be  depended  upon  alone.  They 
form  component  parts  of  one  rational  system. 

No  two  authorities  employ  precisely  the  same  routine  treat- 
ment of  syphilis.     In  the  matter  of  hygiene  we  are  all  more 


I40      PRINCIPLES    OF   THE    TREATMENT    OF    SYPHILIS 

or  less  neglectful.  In  the  matter  of  drugs,  a  generation  back 
one  year  of  treatment,  perhaps  by  iodid  alone,  was  the  most 
a  patient  need  expect;  to-day  mercury  is  universally  employed 
for  two  or  three  years.  Iodid  is  generally  administered  dur- 
ing the  last  year  of  treatment  (and  often  for  some  time  there- 
after), and  the  mercury  is  given  by  mouth,  by  inunction,  or 
by  hypodermic. 

In  such  a  confusion  it  is  impossible  to  do  justice  to  every 
man's  opinions.  One  can  only  describe  one's  own  practice 
and  the  reason  for  it,  leaving  to  objectors  the  privilege  of 
following  any  other  system  that  gives   them   better   results. 

But  first  a  word  of  explanation  as  to  the  cause  of  this  Babel. 
In  the  routine  treatment  of  s)'philis  we  are  attempting  to  come 
as  near  as  possible  to  what  is  confessedly  an  unattainable  ideal 
by  any  of  the  systems  at  present  in  vogue;  viz.,  the  absolute 
and  permanent  prevention  of  all  relapses  of  syphilis.  Now 
syphilis  is  no  exception  to  the  rule:  the  less  curable  a  disease, 
the  greater  the  number  of  "  sure  "  cures  for  it.  For  the  vision 
of  man  is  short  and  the  cold  statistics  by  which  he  attempts 
to  widen  its  scope  are  notoriously  misleading.  If  I  carry  a 
patient  through  the  first  few  years  of  his  disease,  I  send  him 
off  "  cured  "  with  a  confidence  in  my  method  of  treatment 
little  dampened  by  the  relapse  of  another  whom  I  treated  in 
the  same  way  five  years  ago.  For  some  patients  relapse  no 
matter  what  you  do  for  them,  and  others  are  permanently 
cured  under  any  form  of  treatment. 

But  there  are  one  or  two  rules  upon  which  the  routine 
treatment  may  be  based ;  rules  often  broken  nowadays. 

Hygiene  is  of  the  First  Importance. — The  brilliant  effect 
of  drugs  often  blinds  us  to  the  need  of  hygiene  in  syphilis. 
Yet  hygiene  is  all-important. 

The  hygienic  treatment  of  syphilis  includes  all  the  ordi- 
nary laws  of  health.  Regularity  of  meals,  of  sleep,  and  of  the 
bowels  is  necessary.     No  special  diet  is  recjuired.     Air,  exer- 


THE    ROUTINE    TREATMENT  141 

cise,  and  light,  essential  to  all  animal  well-being,  are  particu- 
larly so  in  obstinate  chronic  disease. 

In  obstinate  cases  change  of  air  is  most  useful.  The  nature 
of  the  change  is  not  important :  from  seaboard  to  mountain, 
from  inland  to  shore,  sea  trip  or  dry  and  high.  Six  weeks 
in  any  locality  is  long  enough  for  the  maximum  beneficial 
effect.  This  effect  is  most  strikingly  illustrated  by  the  pa- 
tient's ability  to  take  iodids.  I  have  more  than  once  observed 
that  a  patient  who  could  not  take  enough  of  this  drug  to  con- 
trol his  symptoms  in  New  York  could  readily  do  so  out  of 
the  city.  I  have  remarked  the  same  fact  in  patients  sent  me 
from  Chicago  and  elsewhere ;  they  could  with  ease  and  advan- 
tage tolerate  heavier  medication  in  New  York  than  at  home. 
Many  obstinate  cases  that  fail  to  respond  to  treatment  at 
home,  especially  if  that  home  be  in  the  city,  make  rapid  strides 
toward  recovery  as  soon  as  the  air  and  surroundings  are 
improved.  Mercury  and  iodid  do  not  cure  all  syphilis. 
The  old  chronic  cases,  relapsing  endlessly  in  the  dark  and 
crowded  tenements  of  our  large  cities  and  returning  year 
after  year  to  our  clinics,  often  need  hygiene  far  more  than 
medicine. 

The  Hot  Springs  of  Arkansas.^ — This  Mecca  of  syphi- 
litics  requires  a  word  of  serious  comment.  That  it  has  posi- 
tive value  I  am  sure.  But  its  positive  value  is  reducible  to 
precisely  this :  Under  the  stimulation  of  changed  surround- 
ings and  aided  by  the  hot  baths,  the  old  broken-down  syphi- 
litics,  the  alcoholics,  those  who  have  ruined  their  digestive 
functions  by  inundating  themselves  with  iodid  of  potassium — 
in  short,  all  those  whose  lesions  fail  to  improve  at  home  because 
-they  cannot  tolerate  the  high  doses  of  mercury  and  iodid  re- 
quired  to   cure  them,   can   take   such   doses   at   the    Springs. 


1  The  following  remarks  apply  equally  to  the  syphilis  cure  at  Aachen, 
Germany. 


142      PRINCIPLES    OF    THE    TREATMENT    OF    SYPHILIS 

Whether  this  improvement  is  due  chiefly  to  the  greater  will- 
ingness of  the  patient  to  attend  to  his  cure,  or  to  some  thermic 
or  electric  or  chemical  property  of  the  water,  or  merely  to  the 
change  of  climate  and  the  hot  baths,  I  do  not  know.  But  the 
fact  remains :  at  the  Springs  certain  desperate  and  unman- 
ageable cases  do  better  than  elsewhere. 

But  this  is  not  to  say  that  all  syphilitics  should  go  to 
Hot  Springs;  far  from  it.  In  the  past  five  years  I  have  sent 
only  two  patients  there,  and  of  those  who  have  come  to  me 
from  there,  nine  out  of  ten  were  no  better  off  than  they  would 
have  been  from  intelligent  treatment  at  home ;  while  some  were 
greatly  harmed,  utterly  dilapidated  from  overtreatment,  and 
requiring  months  or  years  to  recover  from  the  effects  of  their 
experience. 

The  statement  that  the  relapse  of  syphilis  is  rarer  after 
a  treatment  at  Hot  Springs  than  after  any  other  course  is 
absolutely  untrue. 

The  Curative  Effect  of  Hygiene. — The  average  pa- 
tient does  well  enough  regardless  of  his  surroundings  just  as 
the  exceptional  patient  gets  well  regardless  of  his  treatment. 
But  the  fundamental  fact  remains  that  every  syphilis  may  re- 
lapse, and  that  the  good  health  of  the  patient  is  the  one  thing 
that  stands  between  him  and  relapse,  mercury  or  no  mercury. 
Mercury  controls  the  disease,  and  doubtless  prevents  relapse 
by  attenuating  the,  spirochetse;  but  it  does  not  destroy  them 
all,  and  it  should  be  our  constant  effort  to  hasten  and  assure 
a  complete  cure  by  keeping  the  patient  in  the  best  possible 
physical  condition. 

Extreme  temperance  In  the  use  of  alcohol  and  tobacco 
(pages  103,  129),  the  avoidance  of  every  excess  in  work,  worry, 
and  pleasure,  plenty  of  fresh  air,  exercise,  and  good  food — 
such  are  the  fundamental  rules.  They  are  not  universally 
applicable,  but  we  must  keep  them  in  mind  and  din  into  our 
patients  the  necessity  for  keeping  "  in  training." 


THE    ROUTINE    TREATMENT  143 

Tonics  must  not  be  Forgotten. — If  the  patient  is  anemic, 
and  this  anemia  does  not  improve  under  mercury,  a  Httle  iron 
helps.  The  proprietary  organic  iron  compounds  are  useful, 
but  I  often  use  the  following: 

^   Sodii  arsenat gr.  ss  to  j    (.03  to  .06  gm.)  ; 

Ferri  reducti ,  3j    (4  gm.)  ; 

Pulv.  rhei 3j  to  jss  (4  to  6  gm.) . 

M.  Fiant  capsules  No.  xxx. 
S. :  One  capsule  t.i.d. 

The  mercury  may  be  embodied  in  this  capsule  and  strych- 
nin may  replace  the  arsenic.  For  neurotic  patients  hypophos- 
phates  and  glycerophosphates  also  help;  while,  if  they  have 
lost  much  weight  cod-liver  oil  and  other  fatty  emulsions  are 
appropriate. 

But  it  is  in  treating  syphilis  of  the  nervous  system 
that  tonics  aad  hygiene  are  peculiarly  applicable.  Mercury 
and  iodids  may  fail  signally — worse  than  this,  if  persist- 
ently pushed,  they  may  do  great  harm  by  impairing  the 
patient's  vitality.  Hence  the  rule  in  such  cases  to  push  the 
specifics  to  the  limit  of  toleration,  then  to  stop  them  entirely 
and  institute  a  course  of  tonics  amidst  the  best  surround- 
ings available,  after  which  return  again  to  the  specifics 
(page  148). 

The  Specific  Tonics. — I  think  that  Zittmann's  decoc- 
tion is  a  remedy  of  positive  value,  especially  in  late  syphilis, 
when  there  is  cachexia,  anemia,  irritable  stomach,  loss  of  appe- 
tite, moderate  constipation,  and  particularly  when  the  stom- 
ach will  not  take  the  iodids  kindly.  The  senna  encourages 
intestinal  action,  the  sarsaparilla  undoubtedly  has  an  influ- 
ence (if  left  out  the  remedy  is  decidedly  less  effective),  and 
the  mercury  is  presented  in  a  dose  calculated  to  exercise  its 
tonic  effect.  But  the  old-fashioned  Zittmann's  decoction  was 
full  of  unnecessary  ingredients   in  its  composition,   and  was 


144      PRINCIPLES    OF   THE    TREATMENT    OF    SYPHILIS 

troublesome  to  make,  difficult  to  take  on  account  of  the  quan- 
tity required  as  a  dose,  and  its  administration  was  surrounded 
by  unnecessary  rules  and  precautions.  Starting  with  the  orig- 
inal decoction,  and  then  modifying  it  by  McDonnell's  formula, 
I  have  gradually  dropped  one  thing  after  another  until  I  now 
use  the  following  formula,  regulating  the  dose  somewhat  ac- 
cording to  the  purgative  effect: 

19   Hydrarg.  chlorid.  corros  ...  gr.  j   (0.06  gm.)  ; 

Aluminis 3ss  (2  gm.)  ; 

Extr.  sarsaparilla Sij  (64  gm.)  ; 

Glycerin Sj   (32  gm.)  ; 

Syr.  sennae §iss  (48  gm.)  ; 

Spts.  anis 3j  (4  gm.)  ; 

Extr.  glycyrrhizas 5j   (4  gm.)  ; 

Aquae  feniculi q.  s.,  ad  oviij   (250  gm.). 

M. 

S. :  oss  t.i.d. 

As  to  the  other  so-called  specific  tonics,  such  as  siiccus 
alterans,  inercauro,  etc.,  some  practitioners  cling  to  them  and 
attribute  excellent  results  to  their  use.  But  apart  from  some 
little  tonic  value  I  think  they  owe  their  reputation  to  being 
employed  when  the  patient  has  been  drowned  in  mercury  and 
iodid,  and  is  ready  to  improve  as  soon  as  he  recovers  from  the 
poisonous  effects  of  these  drugs.  Under  such  circumstances 
any  tonic  (or  no  tonic)  will  work  wonders,  and  whatever 
tonic  happens  to  be  used  gets  the  credit. 

Such  a  condition  is  a  striking  indication  of  the  effect 
of  hygiene.  The  patient  at  the  end  of  his  course  of  "  mixed 
treatment "  Is  apparently  far  worse  than  when  he  began  it ; 
his  lesion  is  uncontrolled,  while  he  has  gone  to  pieces  com- 
pletely under  the  treatment.  But  in  a  few  weeks  zmthoiit  iodid 
or  mercury  he  improves  and  his  symptoms  diminish  with  In- 
credible rapidity  (Case  XXVII,  page  231). 


THE    ROUTINE    TREATMENT 


^45 


Whether  atoxyl  ^  belongs  among  the  specific  tonics  the 
future  must  decide. 

lodids  do  not  Prevent  the  Relapse  of  Syphilis. — Most  of 
us  have  been  educated  in  the  "  mercuriahzation  "  school.  We 
do  not  remember  how  many  treatments  used  to  be  devised  in 
order  to  avoid  giving  mercury.  We  rarely  see  a  patient  who 
has  dragged  along  under  some  "  sarsaparilla  "  or  "  decoction  " 
or  perhaps  under  heroic  doses  of  iodid  in  utter  misery  from 
which  only  mercury  could  save  him.  ]\Iy  father's  greatest 
claim  to  scientific  fame  is  the  fact  that  before  the  International 
Medical  Congress  at  Philadelphia  in  1876,  he  struck  the  first 
blow  for  freedom  from  the  error  that  mercury  properly 
administered  is  a  poison.  Since  that  time  iodid  has  pla3^ed 
a  less  and  less  important  part  in  the  routine  treatment  of  syphi- 
lis. But  though  it  is  now  generally  recognized  that  iodin  does 
not  prevent  relapses  of  syphilis,  this  drug  retains  its  hold  on 
the  last  years  of  the  routine  treatment  of  most  physicians. 

The  precise  reason  for  this  practice  I  do  not  see;  hence 
I  do  not  accede  to  it.  I  employ  iodin  only  for  the  cure  of 
lesions,  never  in  the  routine  treatment  of  syphilis. 

Mercury  does  Prevent  the  Relapses  of  Syphilis.  — Mercury 
certainly  does  not  cure  syphilis.  It  hastens  a  cure  by  destroy- 
ing the  spirocheta  (page  33),  by  curing  certain  lesions,  and 
by  preventing  relapses  of  the  disease.  This  much  everyone 
concedes.  Those  who  go  further  and  claim  that  mercury  ac- 
tually cures  syphilis  must  admit  that  it  does  not  cure  all  cases ; 
therefore,  it  seems  more  prudent  to  believe  that  the  disease 
is  cured  by  time  and  hygiene,  but  only  ameliorated  by  mer- 
cury. 

Mercury,  Administered  in  Small  Doses,  is  a  Tonic. 
— I  quote  my  father's  words  upon  this  subject :  "  This  demon- 
stration of  the  harmlessness  of  mercury,  of  its  tonic  influence, 


Cf.  Lesser,  Deutsche  med.  Wochenschr.,  July  4,  1907. 


146     PRINCIPLES    OF    THE    TREATMENT    OF    SYPHILIS 

I  think  I  have  clearly  made.^  I  have  shown  that  moderate 
doses  of  mercury  continued  for  any  len^h  of  time  (up  to 
several  years,  a  time  amply  long  so  far  as  syphilis  is  concerned) 
not  only  do  not  debilitate  but  act  as  a  tonic,  augmenting  the 
number  of  red  blood  cells  in  health  or  in  S3^philis.  I  have 
amplified  the  subject,  showing  that  mercury  cannot  be  held 
responsible  for  late  lesions.^  Finally,  upon  this  foundation,  I 
devised  a  method  of  treatment  which  I  called  the  tonic  treat- 
ment of  syphilis,^  so  naming  it  because  in  it  mercury  can  be 
used  in  such  a  way  as  to  exercise  its  tonic  influence,  while  at 
the  same  time  it  is  controlling  the  disease.  I  have  been  per- 
sistently misunderstood  in  this  matter.  //  is  not  as  a  tonic, 
or  because  it  is  a  tonic,  that  mercury  cures  syphilis  or  alleviates 
it;  but  mercury  may  be  so  used  in  the  treatment  of  syphilis 
that,  over  and  above  its  specific  influence,  it  may  still  not  only 
do  the  patient  no  harm,  but  may  be  actually  a  tonic  to  him, 
doing  him  good — a  point  that  no  one  has  hinted  at  before,  and 
many  do  not  yet  believe ;  and  on  this  account  only  I  have  called 
this  method  the  tonic  treatment  of  syphilis." 

In  the  Routine  Treatment  of  Syphilis  Small 
"  Tonic  ''  Doses  of  Mercury  are  More  Effective  than 
Poisonous  Doses. — This  statement  is  obviously  true,  and  is 
fortified  by  the  experience  of  past  centuries  when  mercury 
was  administered  in  doses  almost  incredible  to  a  less  heroic 
age.  Yet  these  furious  assaults  were  utterly  inei^cient  in  con- 
trolling relapses. 

So  Long  as  a  Sufficient  Amount  of  Mercury  is 
Exhibited,  it  Matters  not  Whether  it  is  Given  by  the 
Mouth,  by  the  Skin,  or  by  Injection. — The  attitude  of 
many  syphilologists  is  this:  We  find  injections  (or  inunctions) 
far  more  effective  in  curing  symptoms  than  the  administration 


1  Am.  Joiirn.  Med.  Sci.^  Januar}',  1876. 

2  "Treatment  of  Syphilis,"  Trans.  Int.  Med.  Congress,  1876. 

3  "Tonic  Treatment  of  Syphilis,"  New  York,  1877. 


THE  SYMPTOMATIC  TREATMENT  147 

of  pills.  Hence  the  same  discrepancy  must  exist  for  the  pre- 
vention of  symptoms.  The  premise  is  not  absolutely  accurate, 
for  certain  symptoms  are  cured  quite  as  quickly  by  internal 
medication  as  any  other  way,  though  in  many  instances  injec- 
tions and  inunctions  are  certainly  far  more  effective.  But  the 
reason  for  this  effectiveness  is  that  by  these  methods  larger 
doses  of  mercury  are  promptly  absorbed  with  less  danger  of 
poisoning  than  if  the  drug  were  given  by  mouth.  But  this 
quality  of  treatment,  though  excellent  for  the  cure  of  symp- 
toms, is  unnecessary  for  their  prevention,  so  long  as  a  suffi- 
cient amount  of  mercury  can  be  absorbed  by  the  stomach. 

The  contention  for  injections  and  inunctions  in  the  routine 
treatment  is,  therefore,  valid  only  when  the  patient  cannot, 
without  poisoning,  ingest  enough  of  the  drug  to  control  the 
disease. 

As  a  matter  of  clinical  experience,  so  far  as  my  records 
and  my  recollection  go,  there  seems  little  to  choose  between 
the  three  methods  of  administering  mercury  for  the  routine 
treatment  of  syphilis,  except  in  those  patients  who  cannot 
digest  enough  mercury,  or  who  cannot  bear  the  pain  of  injec- 
tions or  the  irritation  of  inunction. 


THE    SYMPTOMATIC    TREATMENT 

The  principles  governing  the  symptomatic  treatment  are 
generally  accepted  and  merely  require  brief  enumeration. 

Excepting  the  Early  Painful  Symptoms,  the  Secondary 
Lesions  of  Syphilis  Call  for  Mercury.— This  is  true  even  of  the 
latest  secondaries. 

The  Early  Painful  Symptoms  Call  for  lodid.— Accepted 
doctrine. 

Gummatous  Lesions  May  be  Cured  by  lodid  alone  but  are 
Better  Managed   by  "Mixed"  Treatment.  — lodid  of  potas- 
sium may  cure  gummatous  lesions  by  its  own  virtues,  even 
12 


148      PRIXCIPLES    OF    THE    TREATMENT    OF    SYPHILIS 

though  no  mercury  has  been  administered.  Thousands  of  cases 
have  proven  this  in  the  past,  yet  nowadays  when  ah  patients 
take  mercury,  it  is  the  fashion  to  behttle  the  effects  of  iodid, 
and  to  attribute  its  virtues  to  "  setting  free  *"  the  mercury. 
But  this  is  a  misrepresentation  of  the  facts.  Recognizing  that 
iodin  has  Httle  or  no  effect  in  preventing  relapses  of  syphihs, 
and  that  its  destructive  effect  upon  the  spirocheta  is  but  slight, 
we  must  see  the  necessity  of  enforcing  its  action  by  mercury. 
\  et  for  the  cure  of  gumma  iodid  is  the  prime  requisite ;  mer- 
cury is  accessory  and  preventive  of  relapse  (Case  XXVI, 
page  202). 

Sclerotic  Tertiary  Lesions  and  Lesions  Difficult  to  Classify 
Require  "Mixed"  Treatment. — For  such  lesions,  for  instance, 
as  tuberculo-ulcerative,  serpiginous  syphilids,  both  iodid  and 
mercury  are  required.  Some  do  better  on  high  doses  of  the 
one,  some  on  the  other. 

Lesions  of  the  Nervous  System,  if  Gummatous, ^  Require 
High  Doses  of  the  Iodid,  if  Arterial,  High  Doses  of  Mercury 
(with  Iodid),  for  Short  Periods,  with  Intermissions  for  Hy- 
gienic Treatment. — The  two  factors  which  dift'erentiate  the 
treatment  of  syphilis  of  the  nervous  system  are  the  importance 
of  scar  tissue  in  causing  symptoms  and  the  importance  of 
hygiene  in  effecting  a  cure. 

We  attack,  let  us  say,  a  syphilitic  hemiplegia.  At  first 
it  yields  to  treatment;  later  the  improvement  ceases.  Then 
one  is  tempted  to  inundate  the  patient  with  mixed  treatment 
in  the  hope  of  clearing  up  these  rebellious  last  traces.  But 
this  often  results  in  destroying  the  patient's  health  without 
improving  his  symptoms.  Thousands  of  sufferers  are  thus 
tortured  with  useless  medication.  How  shall  v:e  avoid  this? 
How  distinguish  what  is  curable  syphiloma  from  what  is  in- 

^  It  is  often  clinically  impossible  to  distinguish  gummatous  from  arterial 
lesions,  and  it  is  accordingly  good  practice  to  push  both  iodids  and  mercury 
in  short  courses. 


THE  SYMPTOMATIC  TREATMENT 


149 


curable  scar?  The  only  solution  is  to  give  short,  sharp  courses 
of  specific  medication  interrupted  by  periods  of  purely  hygienic 
treatment  (page  143).  Thus  we  can  form  an  estimate  of  the 
patient's  condition  and  desist  from  specific  medication  when 
it  proves  futile. 

The  Symptomatic  Treatment  Should  Always  be  Vigor- 
ous.— The  one  thing  probable  (yet  not  quite  certain)  about 
relapses  of  syphilis  is  that  they  are  caused  by  spirochetae,  which 
spirochetse  multiply  in  the  active  lesions  of  the  disease.  Hence, 
as  an  important  adjunct  to  our  routine  treatment  of  syphilis, 
the  symptomatic  treatment  should  be  vigorous  in  order  to 
destroy  as  rapidly  as  possible  these  nests  of  infection.  This  is 
peculiarly  true  of  the  very  lesions  one  is  most  apt  to  neglect. 
The  superficial  secondary  syphilids  of  the  mouth  and  upper 
air  passages  are  among  the  commonest  and  the  most  infec- 
tious lesions  of  syphilis.  Yet  they  are  so  obstinate  and  so 
benign  that  the  patient  neglects  them  if  his  physician  permits, 
and  flatters  himself  on  his  good  health  when  his  mouth  is 
covered  with  active  ulcers  and  mucous  papules. 

This  Vigorous  Treatment  Must  be  Continued  Even  After 
the  Lesion  has  Apparently  Healed. — Neumann  very  justly  in- 
sists upon  this  point:  viz.,  that  the  scars  of  apparently  healed 
syphilitic  lesions  often  contain  areas  of  tissue  which  have  the 
microscopic  appearance  of  active  syphilis.  Hence  the  neces- 
sity of  continuing  vigorous  treatment  after  the  lesion  has 
apparently  healed  (page  36). 

Vigorous  Treatment  is  that  Treatment  which  Effects 
Prompt  Improvement. — We  judge  the  treatment  by  its  effects. 
H  a  gumma  melts  away  under  a  few  drops  of  iodid  and  a 
mild  dose  of  mercury  given  internally,  it  is  quite  unnecessary 
to  have  recourse  to  harsher  methods.  Yet  another  case,  appar- 
ently similar  in  every  other  respect,  may  not  yield  until  50 
minims  a  day  of  potassium  iodid  are  given;  another  may  re- 
quire 100,  another  200,  while  still  another  may  be  obstinate 


I50 


PRINCIPLES    OF   THE   TREATMENT   OF   SYPHILIS 


until  the  mercurial  effect  is  intensified  by  using  inunctions  or 
injections.  Each  lesion  thus  has  its  requirements,  which  can 
be  learned  only  by  experiment.  One  can  never  tell  before- 
hand. An  ancient  destructive  syphilid  often  yields  as  rapidly 
to  light  doses  as  to  heavy  ones.  The  only  rule  to  follow  is 
this :  Each  lesion  has  its  "  dose,"  to  which  it  yields  promptly. 
Find  this  dose  as  rapidly  as  possible,  and  do  not  be  misled  by 
previous  experience  with  other  lesions  into  giving  too  small 
a  dose  to  control  the  lesion  or  too  large  a  dose  for  the  needs 
of  the  case. 

Local  Treatment  Avails  Little. — Local  treatment,  whether 
by  salves  or  powders  or  by  electricity  or  X-rays  or  any  of  the 
newly  discovered  rays,  avails  little  in  syphilis.  To  this  rule 
there  are  two  notable  exceptions.  Secondary  mucous  papules 
and  ulcers  in  and  about  the  mucous  membranes  heal  rapidly 
under  light  cauterization  (page  347)  and  condylomata  wither 
if  kept  dry  (page  346). 

The  local  treatment  of  chancre  and  all  other  open  lesions 
is  palliative  and  cleansing.  Some  form  of  mercury  is  usually 
applied  for  its  slight  local  effect,^  but  for  real  results  we  em- 
ploy systemic  treatment. 

>  Experiment  has  proven  that  inunction  or  injection  of  mercury  encourages 
healing  of  adjacent  syphilitic  lesions;  but  clinically  this  local  action  is  of  little 
importance. 


CHAPTER    XI 

THE  ROUTINE  AND  SYMPTOMATIC   TREATMENT 

THE   ROUTINE    (TONIC)    TREATMENT 

Mercury,  given  in  physiologic  or  "  tonic  "  dose  increases 
the  number  of  red  blood  cells  and  the  percentage  of  hemo- 
globin ;  it  accelerates  vital  changes  and  increases  the  urea  ex- 
creted. It  is  a  true  tonic.  This  tonic  action  is  limited  by  no 
time,  but  only  by  the  amount  of  mercury  administered.  In 
syphilis  we  habitually  give  a  rather  high  dose  in  order  to  con- 
trol the  disease,  and  thus  we  may  mildly  poison  the  patient 
without  salivating  him;  he  then  loses  weight  and  again  be- 
comes anemic.  Yet  this  is  not  due,  as  is  currently  believed, 
to  the  long-continued  course,  but  to  the  long-continued  admin- 
istration of  a  mildly  poisonous  dose. 

Exceptionally  we  even  encounter  a  patient  who  is  sali- 
vated by  very  minute  doses  of  mercury,  whatever  the  method 
of  administration.  Such  a  one  cannot  take  the  drug  to  any 
purpose  in  a  tonic  dose.  He  must  be  poisoned  that  his  disease 
may  be  controlled. 

Moreover,  the  poisonous  dose  of  mercury  varies  not  only 
with  the  dose  of  the  drug,  but  also  with  the  salt  employed 
and  with  the  method  of  administration.  Most  patients  are 
more  readily  poisoned  by  internal  treatment,  for  example,  than 
by  injection.^ 

'  Taking  a  given  syphilitic  lesion  as  a  test,  we  can  often  cure  it  by  hypodermic 
medication  without  poisoning,  whereas  it  resists  even  poisonous  doses  given 
by  the  mouth. 

151 


152      THE    ROUTINE    AND    SYMPTOMATIC    TREATMENT 

Therefore,  the  dispute  between  Fournier  and  most  other 
European  authorities,  on  the  one  hand,  the  the  followers  of 
Hutchinson  and  Keyes,  on  the  other,  resolves  itself  into  this : 
Can  syphilis  be  properly  treated  by  administering  mercury  in 
truly  tonic  doses,  or  not? 

We  maintain  that  this  can  be  done  in  the  average  case ;  our 
opponents  dissent.  After  all,  the  question  is  a  relative  one, 
and  would  be  of  no  great  moment  were  we  not  convinced  of 
the  fact  that  the  most  important  ally  the  physician  can  invoke 
in  the  treatment  of  syphilis  is  habit.  If  you  put  your  patient 
on  a  treatment  calling  for  interruptions  of  six  weeks  here  and 
six  months  there — interruptions  of  which  he  must  recognize 
the  purely  arbitrary  nature — he  promptly  becomes  careless  and 
forgetful.  But  if  you  can  tell  him :  "  Take  so  many  pills 
three  times  a  day,  every  day,  winter  and  summer,"  he  will, 
under  the  shadow  of  his  first  fear,  form  the  habit  which  will 
make  him  almost  regret  the  loss  of  his  treatment  when  he 
stops  it.  Or,  if  injections  are  used,  it  is  much  easier  for  him 
to  remember  to  come  once  a  week  or  twice  a  month  than  to 
be  bothered  with  courses  of  irregular  length  and  frequency. 

Therefore,  when  we  can,  we  employ  the  continuous  tonic 
treatment  of  syphilis.  But  if  the  dose  required  to  check  the 
disease  is  poisonous  to  the  patient,  then  we  use  interrupted 
courses  perforce. 

HOW    TO    ADMINISTER    TREATMENT 

The  Vigorous  Interrupted  Method. — Our  forbears  had 
the  pleasant  habit  of  inundating  the  victim  with  mercury  until 
he  was  wretchedly  salivated,  and  then  setting  him  by  until  an 
outbreak  of  the  malady  gave  the  signal  for  another  mercurial 
onslaught.    In  those  days  the  cure  was  worse  than  the  disease. 

The  only  relic  left  us  of  this  disastrous  system  is  the  prac- 
tice of  returning  annually  to  the  Hot  Springs  for  a  severe 


HOW    TO   ADMINISTER   TREATMENT  153 

"  cure."  This  is  an  extravagant  and  ineffectual  way  to  treat 
syphilis,  which,  be  it  said,  the  physicians  at  the  Springs  do 
their  best  to  discourage. 

The  Modern  Interrupted  Method. — Throughout  the  Con- 
tinent of  Europe  it  is  still  customary  to  give  mercury  in  inter- 
rupted courses.  In  part  this  is  an  inheritance  of  the  ancient 
heroic  system ;  in  part  it  is  due  to  the  feeling  that  relapses  of 
syphilis  occur  with  some  degree  of  constancy  and  are,  there- 
fore, to  be  met  by  an  equally  constant  recurrence  of  treat- 
ments; in  part  to  the  belief  that  mercury,  constantly  admin- 
istered, becomes  poisonous;  and  sometimes  to  the  exigency  of 
the  treatment  employed. 

If  one  uses  inunctions  or  soluble  injections  in  the  routine 
treatment  of  syphilis,  the  treatment  must  be  intermittent. 

In  Germany  and  Italy  intermittent  mercurial  treatment  is 
given  somewhat  as  follows : 

During  the  first  year  three  courses  of  injections  (usually 
soluble)  or  inunctions,  the  first  two  lasting  four  to  six  weeks 
each,  the  last  about  four  weeks. 

During  the  second  year,  two  courses  of  about  four  weeks 
each. 

During  the  third  and  the  fourth  year,  one  four  weeks' 
course. 

In  France  mercury  is  usually  administered  (internally)  for 
two  months  at  the  onset,  then  during  alternate  months  until 
the  end  of  the  second  year,  every  third  month  during  the  third 
year,  every  six  months  during  the  fourth  year. 

Fournier's  course  is  the  following:  At  the  onset  a  sharp 
course  of  eight  weeks,  then  (whatever  the  patient's  condition) 
an  interval  of  six  weeks.  Then  six  weeks  of  treatment  followed 
by  six  weeks'  interval,  then  six  weeks  of  treatment  followed 
by  eight  weeks'  interval  (twice). 

During  the  second  year  three  courses  of  six  weeks  each. 

In  the  third  year  the  administration  of  iodid  is  begim; 


154      THE    ROUTINE    AND    SYMPTOMATIC    TREATMENT 

two  iodid  courses  and  two  mercurial  courses  of  the  same  length 
being  given  alternately. 

During  the  fourth  year  no  mercury,  but  three  iodid 
courses. 

During  the  fifth  and  sixth  years  two  courses  of  iodid  (in 
each ) . 

In  England  and  America  treatment  Is  more  nearly  contin- 
uous, and  usually  by  the  mouth. 

It  were  futile  to  be  more  explicit  or  to  multiply  examples. 
No  two  authors  preach  precisely  the  same  doctrine.  One  can 
only  judge  the  merits  of  the  different  systems  in  the  light  of 
experience,  comparing  published  results  with  cases  witnessed, 
and  thus  weighing  the  practicability  of  each.  Any  one  of 
them  is,  doubtless,  efficient  if  the  patient  can  be  made  to  fol- 
\o\N  it  through. 

The  Continuous  Tonic  Treatment. — My  chief  reason  for 
preferring  this  method  I  have  already  stated.  The  objections 
to  inunctions  and  to  insoluble  injections,  the  only  two  forms 
of  treatment  that  may  be  said  to  require  interrupted  treat- 
ment, need  not  be  repeated  here.  Thirty  years  of  additional 
experience  have  but  confirmed  the  thesis  defended  in  1877  ^ 
that  syphilis  may  be  successfully  treated  by  mercury  in  tonic 
doses. 

Method  of  Administering  Mercury. 2 — The  intelligent 
treatment  of  syphilis  means  the  treatment  of  each  case  accord- 
ing to  its  needs.  No  tw^o  are  precisely  the  same.  Therefore, 
in  laying  down  rules  for  a  system  of  administering  mercury, 
one  must  bear  in  mind  that  exceptions  to  these  rules  are  con- 
stantly cropping  up,  and  that  under  different  circumstances 
it  is  conceivable  that  these  exceptions  should  overwhelm  the 
rule  itself.     Thus  I  have  no  quarrel  with  those  who  prefer 

I ''Tonic  Treatment  of  Syphilis,"  Keyes,  1877. 

2  The  explanation  for  many  statements  in  the  following  paragraphs  will 
be  found  in  the  preceding  chapters. 


THE   TONIC   TREATMENT  155 

interrupted  courses  to  the  tonic  treatment,  nor  yet  with  those 
who  employ  inunctions  or  soluble  injections  in  the  routine 
treatment.  I  follow  the  system  that  gives  me  the  best  results. 
I  prefer  internal  medication  or  insoluble  injections.  I 
leave  the  choice  with  the  patient.  If  he  can  and  will  take  a 
sufficient  dose  internally,  and  if  this  controls  relapses  ade- 
quately, and  he  waxes  fat,  let  him  do  so.  But  if  he  cannot 
digest  the  necessary  dose,  or  if  the  symptoms  incessantly  re- 
lapse, or  if  he  remains  under  weight,  then  some  change  must 
be  made  in  the  system,  and  injections  for  a  time  at  least  are 
useful.  Moreover,  certain  patients  prefer  injections.  I  re- 
spect the  preference,  though  I  do  not  believe  that  in  the  aver- 
age case  injections  are  a  whit  more  effective  for  routine  treat- 
ment than  internal  medication. 


THE    TONIC    TREATMENT 

When  the  patient  comes  with  his  early  lesions  upon  him 
he  requires  (a)  that  these  lesions  be  controlled  and  (b)  that 
their  relapse  be  prevented. 

First,  he  is  given  a  preliminary  instruction,  covering  the 
following  points : 

1.  The  gravity  of  his  disease,  the  duration  of  treatment 
(page  157),  the  probability  that  his  symptoms  will  be  mild 
if  he  attends  to  treatment  (page  124),  the  fact  that  he  must 
continue  treatment  while  well,  just. as  though  he  were  sick. 

2.  The  great  importance  of  hygiene  (page  140),  the  neces- 
sity for  abstinence  from  alcohol  (page  129),  and  moderation 
in  the  use  of  tobacco  (page  130). 

3.  How  others  are  infected,  and  how  to  avoid  this  infec- 
tion  (page  53). 

4.  His  need  to  have  his  teeth  put  in  good  order  and  kept  so 
(page  163). 

5.  The  necessity  of  reporting  every  little  while  that  he 


156      THE    ROUTINE    AND    SYMPTOMATIC   TREATMENT 

may  be  weighed  (page  84)  and  his  throat  (page  336)  and 
urine  (page  165)  examined. 

The  mercurial  treatment  is  then  instituted  by  an  injection 
if  the  lesions  are  grave,  but  usually  with  G.  and  L.  granules 
(page  191). 

Fifty  of  them  are  ordered,  and  (if  it  is  a  Monday  morn- 
ing) he  is  given  this  list : 

Monday    . .  i  i 

Tuesday    i  2  i 

Wednesday 2  i  2 

Thursday   2 

This  means  he  is  to  take  one  granule  after  lunch  and  one 
after  dinner  on  Monday;  one  after  breakfast,  two  after  lunch, 
and  one  after  dinner  on  Tuesday,  etc.,  and  to  report  on  Thurs- 
day. 

If  all  goes  well,  his  list  is  then  continued  to  the  following 
Monday,  thus : 

Thursday    . .  2  2 

Friday 2  3  2 

Saturday 3  2  3 

Sunday 3  3  3 

Monday 4 

\yith  instructions  that  if  he  has  two  colicky,  watery  stools  a 
day,  he  is  to  report  immediatel}^ 

The  dose  is  thus  increased  one  gramde  a  day  until  one  of 
two  things  occurs:  the  colicky  diarrhea  or  the  subsidence  of 
the  lesions. 

If  the  diarrhea  comes  first,  the  dose  is  dropped  to  half 
this  maximum  dose,  and  held  there  until  the  symptoms  sub- 
side, when  the  regular  "  tonic  "  dose 

2 2 2 


THE   TONIC   TREATMENT  157 

is  instituted.  If  the  lesions  disappear  before  diarrhea  occurs, 
the  "  tonic  "  dose  is  instituted  at  once. 

If  the  lesions  refuse  to  subside  within  a  few  days,  they 
are  treated  sccitiiduiii  orfcm  (page  159). 

If  the  patient  cannot  take  the  tonic  dose  of  G.  and  L. 
granules,  gray  powder,  bichlorid,  or  mercury  and  iron  are 
tried  (page  i/o).  If  these  fail,  turn  to  injections  (page  174). 
If  these  are  too  painful,  fumigation  (page  188),  (black  oxid, 
two  drams  once  a  week),  or  inunction  (by  the  German  method 
described  on  page  153). 

This  is  the  fundamental  principle  of  the  old  "  tonic  "  sys- 
tem, shorn  of  its  "  full  dose,"  "  reserve  dose,"  and  "  tonic 
dose."  We  only  retain  the  notion  of  a  minimum  dose.  If 
the  patient  cannot  take  the  dose  stated  above,  his  treatment 
is  not  adequate.  No  matter  how  clean  his  skin  or  how  per- 
fect his  general  health,  he  must  take  a  certain  minimum  dose 
of  mercury  to  minimize  the  danger  of  late  relapses.  This 
dose  is  arbitrary — theoretic,  if  you  will;  ^  yet  without  it  there 
is  no  adequate  prospect  of  cure. 

After  several  months  of  treatment  the  digestion  of  the 
patient  may  begin  to  resent  the  mercury.  Interrupt  treat- 
ment a  week  or  two  and  this  will  usually  pass. 

In  the  second  year  treatment  is  continued  as  in  the  first. 

In  the  third  year  no  treatment  during  the  first  six  months. 
Resume  routine  treatment  durinsr  the  last  six  months. 


'  One  instinctively  looks  upon  the  relapse  of  symptoms  as  the  only  index 
of  inefficient  treatment.  Yet  we  daily  meet  vicious  relapses  in  late  years  in 
patients  whose  lack  of  early  symptoms  led  them  to  take  no  treatment  at  all. 
Without  a  theoretical  minimum  of  mercury  we  have  no  standard  to  go  by 
except  the  patient's  general  health.  Under  well-managed  tonic  treatment  he 
should  slowly  gain  weight  until  he  regains  or  even  exceeds  his  normal  weight; 
his  blood  should  become  normal  and,  within  six  months  or  a  year,  he  should 
be  in  the  pink  of  condition.  This  tonic  effect  keeps  pace  with  the  antisyphilitic 
effect  of  mercury  (though,  as  already  observed,  they  are  by  no  means  identical) 
and  is  the  best  omen  for  the  future. 


158     THE    ROUTINE   AND    SYMPTOMATIC   TREATMENT 

In  the  fourth  year  no  treatment  if  the  patient  has  remained 
clean  for  two  years;  if  not,  three  months  (or  more)  of  treat- 
ment. 

In  the  fifth  year  as  in  the  fourth. 

In  the  sixth  year  matrimony  permitted  if  the  patient  has 
been  two  years  without  lesions  and  without  treatment   (page 

63). 

Such  is  the  routine  treatment  I  prefer.  I  believe  it  as 
efficient  as  any,  and  more  convenient  than  most. 

Tonic  Treatment  after  Late  Relapses. — After  the  lesions 
are  cured,  two  courses  of  six  months,  with  six  months'  inter- 
val and  a  final  course  of  three  months,  suffice.  Even  though 
the  patient  has  had  no  early  treatment,  I  see  no  virtue  in  pro- 
longing the  preventive  course.  But  the  patient  should  be 
under  observation  for  full  two  years,  and  if  during  that  time 
any  further  relapses  occur,  two  more  courses  of  six  months 
should  be  given, 

WHEN   TO    BEGIN    ROUTINE    TREATMENT 

Treatment  Should  be  Begun  as  Soon  as  the  Diagnosis  is 
Made. — Of  this  there  can  be  no  question.  Discussion  centers 
about  the  diagnosis.  Shall  we  begin  treatment  as  soon  as  we 
suspect  syphilis,  shall  we  wait  until  we  are  morally  certain,  or 
shall  we  await  physical  objective  certainty? 

At  the  onset  of  the  disease,  when  the  patient  has  only  the 
primary  lesion  to  show,  nothing  less  than  a  physical  certainty 
justifies  the  beginning  of  treatment.  Four  things  are  re- 
quired for  a  positive  diagnosis  of  chancre:  viz.,  a  character- 
istic sore,  typical  lymph  nodes  in  the  groin,  negative  auto- 
inoculation  and  positive  finding  of  spirocheta  by  an  expert 
microscopist  (page  26).  Lacking  any  one  of  these  we 
must  await  the  confirmation  of  secondary  symptoms,  for 
so   grave  a   diagnosis   must   depend,    not   upon   any   opinion, 


TREATMENT    OF    THE    LESIONS    OF    SYPHILIS  159 

however  expert,  but  upon  the  facts :  physical  certainty  is 
required. 

Later  in  the  disease,  if  the  patient  comes  clean,  unscarred, 
and  with  an  unconvincing  history  of  early  symptoms  and  treat- 
ment and  if  the  period  of  ordinary  routine  treatment  has  not 
yet  elapsed,  treatment  should  be  instituted  on  the  ground  that, 
inasmuch  as  there  is  no  immediate  possibility  of  perfecting 
the  diagnosis,  it  is  prudent  to  take  his  syphilis  for  granted  and 
put  him  through  a  regular  course  of  treatment  rather  than  to 
await  developments,  and  thus  increase  his  risk  of  grave  lesions : 
moral  certainty  suffices. 

The  same  reasoning  applies  to  an  apparently  clean  wife 
impregnated  by  a  husband  in  florid  syphilis.  To  save  the 
child  she  should  follow  a  routine  treatment  through  the  first 
seven  months  of  pregnancy. 

Finally,  if  the  patient  known  to  have  syphilis  comes  with 
some  suspected  secondary  or  tertiary  manifestation,  this  mere 
suspicion  justifies  treatment;  the  diagnosis  is  made  certain  by 
a  test  course  of  treatment  (page  205)  ;  then  a  routine  course 
of  preventive  treatment  is  instituted. 

Thus  under  different  conditions  we  may  require  a  physical 
certainty,  a  moral  certainty,  or  a  mere  suspicion  of  syphilis 
before  instituting  routine  treatment.  But  at  the  onset  of  the 
disease  the  strongest  possible  certainty  is  always  required. 

TREATMENT    OF    THE    LESIONS    OF    SYPHILIS 

No  two  cases  of  syphilis  can  be  treated  alike,  for  in  no 
two  do  the  lesions  of  the  disease  appear  in  like  rotation  or  with 
like  severity.  And  even  if  they  did,  that  would  not  make  gen- 
eral rules  any  more  applicable ;  for  the  treatment  that  cures 
one  lesion  may  not  have  the  least  influence  upon  its  counter- 
part in  another  patient  or  in  the  same  patient  at  another  time. 

Hence  it  is  impossible  to  generalize  in  discussing  the  treat- 


l6o  THE  ROUTINE  AND  SYMPTOMATIC  TREATMENT 

ment  of  the  lesions  of  syphilis.  Each  must  be  attacked  with 
all  the  resources  of  hygiene,  tonics,  and  specific  medication  at 
our  command.  The  treatment  must  be  vigorous,  yet  not  vig- 
orous beyond  the  patient's  needs  (page  149).  The  dose  of 
mercury  or  iodid  required  to  control  each  lesion  must  be  dis- 
covered and  administered  as  soon  as  may  be;  yet  this  dose 
may  not  be  recklessly  exceeded. 

That  new  lesions  appear  from  time  to  time  during  the 
routine  treatment  is  no  indication  that  this  treatment  is  ineffi- 
cient; and,  on  the  other  hand,  the  mildest  mucous  papule  is 
not  too  slight  a  lesion  to  merit  active  treatment  for  its  cure. 

One  special  point,  too,  must  be  born^e  in  mind.  Certain 
lesions  must  run  their  course  in  great  measure  uncontrolled. 
I  have  just  cured  a  chancre  redux  which  I  began  to  treat  six 
months  ago.  I  attacked  it  first  with  mixed  treatment.  The 
patient's  gums  were  touched,  he  was  completely  iodized,  yet 
the  lesion  persisted.  After  a  short  respite  I  gave  a  course  of 
gray-oil  injections.  Again  the  gums  were  touched  and  the 
lesion  much  reduced;  but  it  was  not  cured.  And  now  a  sec- 
ond course  of  gray  oil  has  cured  it.  The  cure  has  been  singu- 
larly slow,  yet  to  have  proceeded  more  viciously  would  have 
so  undermined  the  victim's  health  as  to  make  him  worse  rather 
than  better. 

Certain  other  points  of  treatment  will  come  up  for  con- 
sideration as  we  deal  of  the  lesions  seriatim. 


CHAPTER    XII 

PHYSIOLOGICAL  EFFECTS  AND   TOXICOLOGY  OF 
MERCURY 

Whether  administered  by  the  mouth,  by  the  skin,  by  in- 
halation, or  by  injection,  mercury  enters  the  lymph  channels 
and  is  distributed  throughout  the  body  by  .the  blood  stream. 
Experiments  on  animals  show  that  the  metal  is  deposited 
everywhere  in  the  body,  but  chiefly  in  the  kidneys,  the  liver, 
the  large  intestine,  and  the  spleen. 

Mercury  is  eliminated  in  all  the  secretions,  but  chiefly  in 
the  urine  and  feces. ^  When  given  by  injection  it  appears  in  the 
urine  within  a  few  hours.  Excretion  takes  place  very  slowly. 
Indeed,  certain  German  authorities  have  reported  the  identifica- 
tion of  mercury  in  the  urine  after  incredibly  long  intervals. 
Thus,  Lang-  cites  Landsberg's  case  (interval  ten  months) 
and  Welander's  case  (six  to  twelve  months)  and  then  four 
of  his  own  in  which  mercury  could  be  identified  in  the  urine 
respectively,  seventeen  months,  twenty-three  months,  three 
years,  and  ten  years  after  the  last  treatment. 

BENEFICIAL    EFFECTS    OF    MERCURY 

Mercury  in  small  doses  is  an  excellent  tonic,  quite  apart 
from  its  effect  upon  syphilis.  It  has  also  a  specific  tonic 
effect  upon  patients  debilitated  by  early  syphilis;  it  increases 

1  Schuster  believes  it  is  excreted  chiefly  in  the  feces,  but  most  authorities 
agree  that  the  kidneys  are  the  chief  agents. 

2  "Pathol,  u.  Therap.  d.  Syph.,"  1896,  p.  831. 

161 


l62  TOXICOLOGY   OF   MERCURY 

the  number  of  red  blood  cells  and  the  percentage  of  hemoglo- 
bin. Moreover,  it  cures  the  lesions  of  syphilis,  and  in  great 
measure  prevents  their  relapse. 

The  above  points  are  all  discussed  elsewhere. 

TOXICOLOGY 

It  so  happens  that  to  control  syphilis  we  often  have  to 
give  mercury  in  more  than  the  tonic  dose.  To  cure  the  lesion 
we  have,  in  some  measure,  to  poison  the  patient.  This  poison- 
ing may  show  itself  in  various  ways :  There  may  be  saliva- 
tion, entero-colitis,  nephritis,  besides  evidences  of  local  over- 
irritation  and  general  debility  from  prolonged  overdosage. 
The  susceptibility  to  mercurial  poisoning  varies  widely  in  dif- 
ferent persons. 

But  there  are  a  great  many  other  ways  in  which  the  mer- 
cury does  not  poison.  It  does  not  "  corrode  the  bones  "  or 
"  make  the  hair  fall  out,"  and  there  is  no  such  thing  as  "  mer- 
curial neuralgia."  The  popular  belief  in  these  horrors  is  a 
relic  of  the  days  of  the  antimercurialists. 

Salivation. — Salivation  is  the  commonest  form  of  mer- 
curial poisoning.  It  may  occur  from  the  use  of  mercury  under 
any  form.  The  great  predisposing  cause  to  salivation  is  in- 
flammation of  the  gums,  whether  due  to  tartar,  to  neglect  of 
the  teeth,  or  to  Riggs's  disease.  General  debility  may  be  a 
contributory  cause,  while  the  patient's  native  susceptibility  to 
the  drug  is  the  underlying  element,  causing  one  person  to  be- 
come salivated  much  more  readily  than  another. 

Symptoms  of  Mild  Salivation.— In  many  urgent  syphi- 
litic conditions  mercury  is  pushed  until  "  the  gums  are 
touched,"  i.  e.,  until  mild  salivation  is  produced.  This  is  the 
signal  for  stopping  treatment. 

The  first  symptom  noted  by  the  patient  is  a  coppery  taste 
in  the  mouth.    This  is  accompanied  by  a  very  heavy  disagree- 


TOXICOLOGY  163 

able  odor  to  the  breath;  the  tongue  becomes  edematous  and 
shows  the  marks  of  the  teeth  along  its  edge;  the  gums  bleed; 
the  teeth  feel  sore  and  elongated. 

Examination  of  the  gums  reveals  localized  areas  of  con- 
gestion, especially  about  the  lozver  incisors  or  about  any  de- 
cayed tooth.  When  the  lesions  are  more  pronounced  the  gums 
actually  ulcerate.  The  pathognomonic  mercurial  ulceration 
appears  behind  the  lozver  incisors  and  back  of  the  lower 
wisdom  teeth.  Ulcerations  may  occur  elsewhere  in  the 
mouth,  and  it  may  be  almost  impossible  to  distinguish  the 
lesions  due  to  the  medicine  from  those  caused  by  the  disease 
(page  343). 

Actual  salivation  is  usually  slight  at  first,  though  in  some 
cases  the  excessive  flow  of  saliva  is  the  earliest  symptom. 

Symptoms  of  Severe  Salivation. — Nowadays  one  does 
not  see  "  good,  old-fashioned "  salivation,  the  patient  de- 
pressed, feverish,  stupid,  his  tongue  swollen  beyond  recog- 
nition and  gangrenous  in  spots,  a  constant  stream  of  ropy 
saliva  drooling  from  his  swollen  lips,  his  teeth  loosened  and 
falling,  even  his  jaws  becoming  necrotic,  and  his  breath 
permeating  the  atmosphere  with  an  intensely  disgusting  fetid 
odor. 

Yet  conditions  intermediate  between  this  and  the  mild  type 
of  salivation  described  above  are  often  seen. 

Treatment  of  Salivation. — So  important  is  the  care  of 
the  mouth  in  the  prophylaxis  of  salivation  that  the  patient 
about  to  take  a  course  of  mercury  should  be  carefully  in- 
structed how  to  keep  his  mouth  in  good  condition. 

He  must  first  have  his  teeth  filled  and  thoroughly  cleaned 
by  a  dentist. 

He  must  brush  his  teeth  morning  and  night. 

He  must  rinse  his  mouth  morning  and  night  with  chlorate 

of  potash,  gr.  xv  (three  5-grain  tablets),  dissolved  in  half  a 

glass  of  water  or  with  an  alkalin  mouth  wash. 
13 


164  TOXICOLOGY    OF    MERCURY 

He  must  smoke  little.^ 

He  must  report  the  instant  his  gums  become  swollen  or 
sore. 

The  treatment  of  mild  salivation  consists  in  painting  the 
gums  with  one  of  the  following  solutions : 

I^   Tr.  myrrh.,  . 

Tr.   iodi  comp.  V aa  oj    (4  gm.). 

Aquae 
S.  Apply  to  gums  once  or  twice  a  day. 
Or 

^  Acid  lactic oj    (4  gm.)  ; 

Aquae oij    (8  gm.). 

S.  Apply  to  gums  once  a  day  (Tennesson). 
Or 

3?   Acid  chromic gr.  xv   ( i   gm.)  ; 

Aquae 5v   (20  gm.). 

S.  Apply  to  gums  every  other  day  (Berdal). 

The  ulcerations  may  be  touched  once  a  week  with  liq. 
hydrarg.  nitratis,  fifty  per  cent,  or  with  the  solid  stick  of 
nitrate  of  silver.  Meanwhile,  let  the  patient  suck  during  the 
day  two  or  three  tablets  (aa  gr.  v)  of  chlorate  of  potash. 

The  bowels  must  be  kept  open  (they  are  usually  loose, 
anyway)  and  the  mercury  stopped. 

For  severe  cases  free  purging  and  diuresis,  hot  baths,  a 
milk  diet,  and  suspension  of  the  mercury  constitute  the  most 
important  treatment.  The  local  applications  may  be  used  as 
in  mild  cases,  but  cauterization  had  better  be  omitted.  Ulcer- 
ation of  the  cheeks  may  be  lessened  by  separating  them  from 
the  teeth  with  pledgets  of  cotton  dipped  in  boric-acid  solu- 

'  I  am  not  sure  that  the  irritation  of  tobacco  is  an  important  contributory 
cause  of  salivation,  but  I  know  it  predisposes  the  patient  to  syphilitic  mouth 
lesions. 


TOXICOLOGY  165 

tion  or  with  a  piece  of  raw  turnip.  Belladonna  or  atropin 
theoretically  ought  to  stop  the  salivary  flow,  but  they  are  not 
very  efficient.  Chlorate  of  potash,  four  per  cent,  administered 
internally  in  doses  of  one  or  two  ounces  a  day  is  highly  prized, 
but  I  cannot  say  I  have  seen  it  do  much  good. 

Entero-colitis.  —  A  sharp  diarrhea  with  colic  usually  accom- 
panies severe  salivation.  This  is  due  to  the  elimination  of  the 
mercury  into  the  bowel. 

But  internal  administration  of  mercury  sets  up  an  irrita- 
tion of  the  bowels  by  direct  local  action.  Hence  result  grip- 
ing pains  and  diarrhea,  which  may  even  go  on  to  chronic  co- 
litis with  constant  diarrhea  and  passage  of  blood  and  mucus, 
marked  debility  and  anemia. 

To  prevent  this  is  the  art  of  managing  the  internal  treat- 
ment. 

To  cure  it  stop  the  mercury,  put  the  patient  on  a  fluid  diet 
without  milk  and,  after  giving  a  sharp  purge,  administer  bis- 
muth (gr.  x),  beta-naphthol  bismuth  (gr.  x),  castor  oil  (TTlx), 
and  salol  (gr.  v),  or  opium. 

Mild  cases  are  promptly  relieved  by  stopping  the  mercury. 

Nephritis. — The  normal  kidney  secretes  mercury  in  small 
doses  perfectly  kindly.  But  mercury  may  produce  congestion 
of  the  kidney  or  nephritis  either. 

1.  When  the  kidneys  are  diseased,  or 

2.  When  mercury  is  given  in  poisonous  dose. 

Any  form  of  acute  or  chronic  nephritis  makes  the  kidneys 
a  poor  filter  for  mercury,  and  since  mercurial  nephritis  is  the 
rarest  form  of  mercurial  poisoning,  there  is  always  room  for 
suspicion  that  the  kidney  is  chiefly  at  fault.  This  is  further 
emphasized  by  the  fact  that  there  occurs  an  acute  secondary 
syphilitic  nephritis  which  may  be  mistaken  for  mercurial 
nephritis  (cf.  Ledermann  ^). 

^  Dermat.  Zeitschr.,  1905,  vol.  xi. 


l66  TOXICOLOGY   OF   MERCURY 

The  symptoms  of  mercurial  nephritis  are  those  of  acute 
congestion  of  the  kidneys  from  whatever  cause. 

The  treatment  consists  in  stopping  the  mercury.  The  prog- 
nosis is  excellent. 

The  chief  practical  point  in  regard  to  nephritis  is  that  the 
urine  should  he  examined  when  mercurial  treatment  is  insti- 
tuted, and  should  he  repeatedly  examined  during  any  severe 
course  of  mercury. 

Albuminuria  or  nephritis  does  not  contraindicate  the  ad- 
ministration of  mercury,  but  does  give  warning  that  it  must 
be  given  in  small  doses  and  with  constant  attention  to  the  con- 
dition of  the  renal  function. 

Dermatitis. — Some  skins  are  very  sensitive  to  inunction, 
and  in  general  the  hairy  portions  of  the  skin  become  irritated 
most  readily. 

Mercurial  dermatitis  begins  as  an  erythema  which,  in 
severe  cases,  goes  on  to  an  acute  eczematous  condition  (mer- 
curial eczema). 

There  is  also  an  extremely  rare  dermatitis,  due  to  a  peculiar 
individual  susceptibility  to  the  internal  administration  of  mer- 
cury. The  eruption  is  scattered,  erythematous,  urticarial,  or 
eczematous.  It  burns  or  itches ;  in  fact,  is  a  typical  toxic  erup- 
tion. Though  said  to  be  commonest  after  internal  adminis- 
tration, the  only  case  I  have  seen  was  a  sharp  urticaria  follow- 
ing injection. 

The  treatment  consists  in  stopping  the  mercury  (for  a 
time,  and  then  using  it  in  small  doses),  soothing  lotions,  and 
catharsis. 

Ill-effects  of  Prolonged  Mercurialization. — Mercury  can 
be  given  quite  indefinitely  in  non-toxic  doses.  But  prolonged 
courses,  even  if  only  moderately  severe,  produce  emaciation, 
anemia,  and  general  vital  deterioration,  such  as  would  ensue 
upon  any  chronic  poisoning.  Nowadays  such  a  condition  is  seen 
only  in  overtreated  cases  of  syphilis  of  the  nervous  system. 


CONTRAINDICATIONS  167 

If  the  medication  has  been  much  prolonged,  or  extremely 
severe,  the  patient  may  be  left  with  chronic  nephritis  or  gastro- 
enteritis, from  which  he  will  never  recover. 


CONTRAINDICATIONS 

There  are  no  absolute  contraindications  to  the  occasional 
use  of  mercury;  witness  the  universal  employment  of  calomel 
as  an  occasional  cathartic,  even  in  nephritis. 

But  certain  conditions  constitute  relative  contraindications 
to  its  continued  use.  Such  are  the  acute  infectious  diseases, 
tuberculosis  and  other  wasting  diseases,  and  nephritis. 

When  such  conditions  complicate  syphilis  they  contrain- 
dicate  the  use  of  mercury  only  thus  far :  the  drug  must  be 
given  with  extreme  caution. 

During  an  acute  infectious  disease  it  may  usually  be 
stopped  entirely. 

//  there  is  tuberculosis  or  other  chronic  disease,  the  organ- 
ism is  peculiarly  susceptible  to  mercurial  poisoning,  and,  ac- 
cordingly, the  drug  must  be  given  in  small  doses,  and  its  effects 
carefully  watched,  for  the  slightest  mercurial  poisoning  is 
likely  to  lessen  the  patient's  resistance  and  to  encourage  the 
progress  of  any  complicating  disease.  Thus  the  unnecessarily 
vigorous  treatment  of  Case  V  (page  19)  terminated  in  sali- 
vation and  diarrhea ;  the  diarrhea  persisted  after  the  cure  of 
salivation,  and  examination  revealed  the  presence  of  extensive, 
inoperable  rectal  carcinoma.  I  have  no  doubt  the  progress  of 
this  disease  was  greatly  encouraged  as  well  by  the  syphilis  as 
by  its  overenergetic  treatment. 

When  syphilis  and  tuberculosis  coexist,  conditions  are  pre- 
cisely similar.  The  tuberculosis  is  fed  both  by  the  syphilis  and 
its  overtreatment.  But  a  moderate  treatment,  calculated  to 
overcome  the  patient's  syphilis  without  impairing  his  vitality, 
benefits  also  the  tuberculosis.     Under  such  circumstances,  if 


168  TOXICOLOGY   OF   MERCURY 

an  intense  mercurial  effect  is  desired,  it  is  safer  to  use  soluble 
injections,  the  poisonous  effects  of  which  are  more  immediately- 
appreciable  and  more  short-lived. 

Complicating  nephritis  produces  almost  identical  conditions. 
It  does  not  absolutely  contraindicate  the  use  of  mercury  (page 
165),  but  it  does  require  great  caution  and  constant  estima- 
tions of  the  urinary  and  circulatory  conditions  (urinalysis, 
estimation  of  blood  pressure). 


CHAPTER    XIII 

ADMINISTRATION  OF  MERCURY 

Mercury  is  administered  in  syphilis  internally,  by  inunc- 
tion, by  intramuscular  or  subcutaneous  or  intravenous  injec- 
tion, and  by  fumigation.  It  may  also  be  applied  locally,  but 
is  rarely  so  used.  Mercurial  baths  and  mercurial  shirts  or 
sacks  are  no  longer  generally  employed. 

Internal  administration  of  mercury  remains  the  most  popu- 
lar form  of  treatment,  though  of  late  years  intramuscular  in- 
jections are  constantly  gaining  in  popularity.  This  latter 
method  appeals  to  the  physician  on  the  ground  of  precision  and 
efficacy;  it  forces  the  patient  to  keep  under  the  eye  of  his 
adviser.  Moreover,  it  spares  the  patient's  digestion.  Small 
wonder,  then,  that  this  method  is  employed  exclusively  by 
certain  physicians,  beloved  above  others  by  certain  patients. 
Yet  its  inconveniences  are  such  as  to  preclude  its  universal 
acceptance  until  it  is  proven  as  peculiarly  effective  in 
preventing  relapses  as  it  often  is  in  curing  lesions.  This 
proof  is  not  yet;  indeed,  so  far  as  present  evidence  goes,  a 
routine  cure  by  injections  is  no  more  essentially  curative 
than  one  by  inunctions  or  by  internal  treatment.  It  is  neces- 
sary constantly  to  remind  oneself  that  many  lesions  heal 
quite  as  rapidly  under  other  methods  of  administering  mer- 
cury, and  that  many  of  the  failures  in  cases  treated  by 
internal  medication  are  due  to  the  carelessness  with  which 
their    cure    is    conducted,    not   to    any    fault    inherent    in   the 

method. 

169 


lyo  ADMINISTRATION    OF    MERCURY 

INTERNAL    ADMINISTRATION 

The  preparations  commonly  employed  are  protiodid,  gray 
powder,  bichlorid,  and  blue  pill. 

Protiodid  (Hydrarg.  Iodid.  Flav.). — If  the  patient  can 
take  them  I  usually  employ  for  the  routine  treatment  Garnier 
and  Lamoureux's  granules  of  (green)  protiodid;  not  because 
they  contain  iodin,  for  this  is  not  present  in  therapeutic  quan- 
tity; nor  because  they  agree  with  the  patient,  for  they  are 
not  peculiarly  easy  to  digest.  But  their  double  virtue  consists 
in  this :  they  control  the  symptoms  of  syphilis  very  efficiently, 
and  in  case  of  poisoning  they  strike  the  bowel  rather  than  the 
mouth — they  purge  before  they  salivate.  Hence  they  possess 
the  great  practical  virtue  of  being  the  safest  form  in  which  to 
confide  mercury  to  the  patient's  own  hands.  With  any  other 
preparation  he  may  produce  grave  salivation  before  he  realizes 
what  is  wrong;  with  these  granules  he  produces  only  a  sharp 
diarrhea. 

The  granules  contain  a  centigram  each  of  protiodid. 
The  minimum  tonic  dose  is  six  granules  a  day. 

Other  iodids  of  mercury  I  do  not  employ  for  internal 
treatment.  The  biniodid  is  too  poisonous.  Yellow  protiodid 
tablets,  the  favorite  American  remedy,  in  the  routine  treatment 
of  syphilis  are  so  vilely  irritating  to  the  bowel  that  the  most 
hidebound  constipation  scarcely  resists  the  explosive  effects 
of  the  minimum  tonic  dose;  viz.,  one  grain  a  day.^ 

Gray  Powder  (Pulv.  Hydrarg.  Cum  Greta). — This  is 
an  excellent  preparation,  preferred  in  England  to  all  others. 
Six  grains  a  day  is  the  tonic  dose.  It  may  be  administered  in 
one-  or  two-grain  tablets.  Some  patients  take  this  far  better 
than  the  protiodid  (G.  and  L.).    Indeed,  I  have  often  given  as 

'  It  is  a  great  pity  that  in  therapeutic  efficiency  no  other  manufacturer  has 
been  able  to  equal  the  G.  and  L.  granules.  They  are  chemically  impure;  that 
is  manifest,  yet  they  work  better  than  the  purest  yellow  protiodid. 


INTERNAL    ADMINISTRATION  171 

much  as  fifteen  grains  of  gray  powder  a  day  in  attempting 
to  control  symptoms ;  yet  very,  very  few  patients  can  take  even 
ten  G.  and  L.  granules  a  day  for  any  length  of  time. 

BiCHLORiD  (Hydrarg.  Chlorid.  Corrosiv.  ) . — If  given 
alone,  this  preparation  must  be  put  in  pill  or  capsule,  for  in 
tablet  for^n  it  is  likely  to  irritate  the  throat  and  esophagus.  It 
is  not  much  employed  in  early  syphilis,  but  in  the  later  stages 
of  the  disease  is  the  favorite  mercurial  ingredient  of  "  mixed  " 
treatment  (page  202).  The  minimum  tonic  dose  is  one  six- 
teenth grain. 

Blue  Pill  (Pil.  Mass^  Hydrarg.). — This  is  another 
preparation  of  mercury  popular  in  the  late  rather  than  in  the 
early  days  of  the  disease.  The  minimum  tonic  dose  is  three 
grains  a  day.  But  twice  or  three  times  that  amount  may  often 
be  given.  A  patient  using  this  preparation  should  be  under 
constant  observation,  as  it  strikes  the  gums  more  suddenly 
and_ severely  than  any  other  form  of  internal  treatment. 

Calomel  (Hydrarg.  Chlorid.  Mitis). — This  is  no 
longer  used  in  the  internal  treatment  of  syphilis. 

Tannate  of  Mercury. — This  is  favored  by  certain  prac- 
titioners. The  tonic  dose  is  three  to  six  grains  a  day.  I  have 
not  been  able  to  discern  its  peculiar  virtues.  It  appears  to  vary 
in  strength  in  different  preparations. 

Many  other  preparations  are  fancied  by  certain  individuals, 
but  their  vogue  is  slight,  their  merits  ill-defined.  It  is  proper, 
however,  to  mention  two  old  and  familiar  mixtures  containing 
mercury.    The  one  is  a  pill  of  mercury  and  iron  : 

^  Massse  hydrargyri,  -"v 

Ferri  reducti,  V aa     3j   (4  gm.)  ; 

Gum  tragacanth,      ) 

Glycerin q.  s. 

M.     Fiant  pil.  No.  Ix. 

S.     One  pill  after  each  meal. 


172  ADMINISTRATION    OF    MERCURY 

The  other  is  often  called  Sir  As t ley  Cooper's  tonic : 

^   Hydrarg.  chlorid.  corrosiv.    gr.   i-ij    (.06  gm.)  ; 

Tr.  cinchonse  co oiv   ( 100  c.c). 

M. 

S.     Teaspoonful  in  water  after  meals. 

These  form  admirable  combinations  for  the  exhibition 
of  the  iron  tonic  or  the  bitters  in  conjunction  with  mer- 
cury. Either  may  be  employed  in  the  routine  treatment. 
Zittmann's  decoction  (page  143)  is  only  employed  in  late 
syphilis. 

Rules  for  Treatment. — Besides  the  care  of  the  mouth  and 
the  occasional  urinalysis  (page  166),  the  following  precau- 
tions are  necessary : 

Do  Not  Give  Opium  With  Mercury. — The  callousness 
with  which  Continental  authorities  prescribe  opium  in  the 
treatment  of  syphilis  is  quite  inexplicable.  Syphilis  confers 
no  immunity  to  this  drug.  The  opium  habit  is  as  readily 
formed  by  a  syphilitic  as  by  any  other. 

Happily,  we  need  insist  no  further.  On  this  point  American 
practice  is  eminently  sane.  Though  recognizing  that  opium  so 
constipates  the  patient  as  to  permit  him  to  take  mercury  inter- 
nally in  larger  doses  than  is  otherwise  possible,  we  bow  before 
the  greater  evil,  the  danger  of  forming  an  opium  habit.  The 
constipating  effect  of  iron,  though  less  than  that  of  opium, 
makes  it  doubly  useful  in  the  mercury  and.  iron  pill  mentioned 
above. 

Do  Not  Begin  With  a  Full  Dose. — In  order  to  per- 
mit the  patient  to  take  a  full  dose  comfortably,  it  is  safe  prac- 
tice to  begin  with  half  the  dose  and  work  up  gradually ;  thus 
for  protiodid,  begin  with  three  granules  a  day,  and  increase 
one  daily  until  six  are  being  taken;  for  gray  powder,  begin 
at  three  grains  a  day,  and  increase  a  grain  a  day ;  for  blue  pill, 
begin  at  one  and  a  half  grains  a  day. 


INTERNAL   ADMINISTRATION  173 

To  Spare  the  Patient's  Digestive  Organs  an  Inter- 
mission OF  A  Few  Days  may  be  Occasionally  Necessary. 
— The  advent  of  summer  and  fresh  fruit  introduces  in  many- 
patients  an  inabihty  to  take  the  full  dose  of  mercury.  Regu- 
lation of  diet  may  help  overcome  this;  but  it  is  often  neces- 
sary to  intermit  treatment  a  week  or  so.  Such  intermissions, 
even  though  occurring  as  often  as  six  times  a  year,  do  not 
invalidate  routine  treatment.  It  is  no  more  necessary  that  a 
patient  should  take  so  many  pills  every  day  than  that,  under 
the  theory  of  interrupted  treatment,  he  should  respect  certain 
definite  intervals. 

Merits  of  Internal  Treatment. — Continuous  internal  treat- 
ment has  the  merit  of  being  easy  to  remember  and  little  trouble 
to  follow.  But  it  may  be  impossible  for  the  patient  to  digest 
mercury  in  sufficient  quantity  for  the  control  of  symptoms  or 
for  their  cure.  It  is  the  least  efficient  way  to  administer  the 
drug;  yet  it  is  often  quite  efficient  enough.  If,  in  the  routine 
treatment,  it  can  be  taken  in  the  necessary  minimum  dose,  and 
so  prevents  relapses,  or,  if  in  the  symptomatic  treatment  it 
causes  the  lesions  to  heal  promptly,  there  is  no  need  to  employ 
other  and  less  convenient  methods. 

Yet,  in  employing  internal  medication,  we  must  guard 
against  the  patient's  carelessness.  We  must  not  permit  him 
to  neglect  even  mild  symptoms  or  to  become  indifferent  as  to 
the  regularity  of  his  treatment.^  He  must  be  seen,  examined, 
and  encouraged  at  least  every  three  months. 

The  theory  of  the  minimum  dose  must  be  clearly  under- 
stood. We  recognize  that  mercury  prevents  relapses.  We 
recognize  that  in  certain  cases  even  without  mercury  (or  any 
other  preventive)  no  relapses  occur,  or  many  years  elapse  be- 

1  One  might  infer  that  this  excludes  internal  treatment  from  the  clinic. 
But  I  cannot  say  that  I  have  found  any  way  of  adequately  treating  syphilis  in 
the  poor:  they  simply  will  not  take  any  care  of  themselves  after  their  symptoms 
are  relieved. 


174  ADMINISTRATION    OF    MERCURY 

tween  relapses.  Hence  we  are  bereft  of  any  clinical  evidence 
to  prove  that  we  are  giving  the  proper  preventive  amount  of 
mercury;  we  have  to  depend  upon  statistics  and  clinical  im- 
pressions as  to  the  proper  average  dose.  We  know  that  the 
dose  that  will  prevent  relapses  in  one  case  will  not  do  so  in 
another.  But  we  know  this  only  after  the  fact;  i.e.,  after 
relapse  has  proven  a  given  dose  inefficient.  Thus  we  must 
deal  in  generalities;  we  must  insist  that  a  patient  take  a  defi- 
nite amount  of  mercury  whether  he  seems  to  need  it  or  not. 
Hence  the  minimum  tonic  dose. 

But  one  concession  may  be  made  to  the  individual  patient. 
This  minimum  dose  must  be  given  in  such  a  way  as  to  be  a 
tonic  dose;  the  patient  must  thrive  upon  it.  He  must  become 
free  from  syphilitic  lesions ;  he  must  be  in  good  trim ;  he  must 
not  lose  weight;  and  if  he  has  lost  weight,  he  must  regain  it, 
and  his  blood  must  shoM^  a  normal  red  cell  and  hemoglobin 
count.  H  under  the  minimum  tonic  dose  of  a  given  salt,  the 
patient  does  not  answer  satisfactorily  (in  the  main)  to  the 
above  tests,  some  change  must  be  made  either  in  his  hygiene 
or  his  medicine. 

INTRAMUSCULAR    INJECTIONS 

The  preparations  of  mercury  employed  for  injections  are 
either  soluble  or  insoluble.  The  chief  soluble  prepai-ations  are 
the  bichlorid,  the  benzoate,  and  the  biniodid. 

The  chief  insoluble  preparations  are  the  salicylate,  gray  oil, 
and  calomel. 

Bichlorid. — This  salt  is  used  in  one  per  cent  or  two  per 
cent  solution  with  salt  solution,  various  quantities  of  salt  being 
used  by  different  authorities.  The  following  is  an  excellent 
combination : 


INTRAMUSCULAR    INJECTIONS  175 

19   Hydrarg.  chlorid.  corrosiv.  gr.  xv-xxx  (1-2  gm.)  ; 

Sodii  chlorid gr.  x   (0.6  gm.)  ; 

Aquje  destillat oiij   (  100  c.c). 

Dose:   i  c.c.  (Trtxv). 

Benzoate : 

^   Hydrarg.  benzoat gr.  xv   (i   gm.)  ; 

Ammonii  benzoat gr.  Ixxv   (5  gm.)  ; 

Aciuse  destillat q.  s.  ad  oiij    (100  c.c). 

Dose:   i  c.c.  (trtxv). 

BiNiODiD. — The  red  iodid  of  mercury  is  employed  either 
in  oily  solution  or  in  so-called  "  serum  "  or  mixed  with  potas- 
sium iodid.  It  appears  under  various  proprietary  names.  I 
have  employed  cypridol,  the  Hannam's  and  Lafay's  sera. 
These  preparations  are  popular  on  the  Continent,  but  are  little 
used  here.     I  prefer  the  following: 

^   Hydrarg.   biniodid oss   (2  gm.)  ; 

Potass,  iodid gr.  xv   ( i   gm.)  ; 

Aquas  destillat   ad  oiij    (100  c.c). 

Among  the  soluble  preparations  the  succinamidate,  forma- 
midate,  oxycyanid,  hermophenyl,  and  enesol  deserve  mention 
as  being  well  spoken  of,  but  they  have  not  gained  general 
favor. 

Salicylate. — This  may  be  put  up  in  five  per  cent  or  ten 
per  cent  strength.     The  mixture  I  employ  is : 

I^   Hydrarg.  salicylate gr.  xlviii  (3  gm.)  ; 

Albolin   (sterilized)    oj   (30  gm.). 

Shake.     Dose:  trtx  (0.7  c.c). 

The  salicylate  settles  to  the  bottom  and  has  to  be  distrib- 
uted by  vigorous  shaking.  The  admixture  of  a  little  lanolin 
makes  a  better  suspension  but  a  thicker  mixture. 


176  ADMINISTRATION    OF    MERCURY 

Gray  Oil. — Gray  oil  is  an  emulsion  of  metallic  mercury. 
It  is  usually  employed  in  fifty  per  cent  strength,  and  is  in  this 
form  a  thick  mixture  which  has  to  be  heated  before  injecting 
(and  requires  that  needle  and  syringe  be  heated  as  well),  and 
can  be  prepared  only  by  expert  chemists.  After  employing 
Lafay's  gray  oil  for  about  a  year,  I  find  that  the  following 
formula  is  equally  effective,  quite  as  painless,  is  easily  pre- 
pared by  any  chemist,  and,  being  fluid,  requires  no  heating. 
Its  only  disadvantage,  the  increase  in  dosage,  does  not  seem 
to  make  it  more  painful. 

The  formula  is  that  of  Lafay  (in  which  the  amount  of 
mercury  and  of  lanolin  may  be  varied  if  the  physician  so  de- 
sires) : 

^   Hydrarg.  bidestillat.^ oijss   (10  gm.)  ; 

Albolin    oiij    ( 13.5  gm.)  ; 

Lanolin   ojss   (46.5  gm.). 

Shake.     Dose:  lUij-vj   (o.i  to  0.4  c.c). 

Calomel. — Calomel  oil  is  made  by  pulverizing  the  drug, 
washing  in  boiling  alcohol,  drying  in  an  oven,  and  then 
thoroughly  mixing  with  ten  parts  of  sterilized  albolin.  Dose : 
0.5  c.c. 

Method  of  Administration.  —  The  soluble  salts  may  be 
given  subcutaneously,  but  this  method  is  unnecessarily  painful. 
They  are  best  given — and  the  insoluble  preparation  must  be 
given — into  the  substance  of  some  thick  muscle.  Injection 
of  an  insoluble  preparation  subcutaneously  invites  abscess  or 
gangrene. 

The  site  usually  selected  for  injection  is  the  buttock.  The 
pectoral  muscles  or  the  thick  muscles  of  the  interscapular  re- 
gion or  loin  may  also  be  utilized.  Successive  injections  are 
given  on  alternating  sides,  and  no  two  injections  should  be 
put  within  an  inch  of  each  other  on  the  same  side. 

»This  is  the  "dentists'  mercur}\" 


INTRAMUSCULAR    INJECTIONS  177 

Various  landmarks  have  been  suggested  in  order  to  pre- 
vent injury  to  any  important  structures.  The  simplest  rule 
is  that  of  Galliot :  Run  a  vertical  line,  dividing  the  gluteal 
region  into  an  inner  third  and  an  outer  two  thirds ;  lay  a 
horizontal  line  two  finger-breadths  above  the  great  trochanter. 
Where  the  lines  intersect  is  Galliot's  point.  Injections  may 
be  safely  made  in  this  region  and  to  the  upper  and  outer 
side  of  it. 

Grosz/  in  an  exhaustive  monograph,  disapproves  of  Gal- 
liot's point,  and  recommends  the  following: 

1.  A  point  midway  between  the  ischial  tuberosity  and  the 
upper  edge  of  the  trochanter  on  a  horizontal  line  at  a  level 
with  the  latter. 

2.  A  point  directly  above  this  and  midway  to  a  line  join- 
ing the  anterior  superior  spines. 

3.  A  point  on  the  same  (horizontal)  level  as  No.  2  and 
halfway  between  the  trochanter  and  the  intergluteal  fold. 

The  implements  are  a  sterilizable,  hypodermic  syringe 
(preferably  all  glass,  as  metal  instruments  are  amalgamated 
by  mercury),  and  a  needle  two  inches  long  and  of  ample  cali- 
ber ; "  for  very  stout  persons  the  needle  should  be  two  and  a 
half  inches  long. 

Tech  NIC. — Boil  the  implements,  wash  your  hands,  and, 
making  the  patient  lie  upon  his  face,  rub  the  buttock  well  with 
alcohol.  Then  plunge  the  needle  up  to  the  hilt  in  the  appointed 
spot;  if  the  pain  warrants  it,^  withdraw  the  needle  and  plunge 
it  in  an  adjoining  spot.^  Then  fill  the  syringe  with  the  solu- 
tion to  be  employed,  and  note  whether  any  blood  is  oozing 
from  the  needle;  if  so,  change  its  location;  if  not  screw  on  the 

*  Archiv  f.  Dermat.  u.  Syph.,  1904,  vol.  Ixxii,  p.  i.  Cf.  also  La  syphilis, 
1906,  vol.  iv,  p.  71. 

^  I  use  a  No.  19  standard  wire  gauze. 
^  This  one  can  judge  only  by  experience. 

*  If  you  strike  bone  withdraw  a  little. 


178  ADMINISTRATION    OF   MERCURY 

syringe,  aspirate  the  minute  bubble  of  air  from  the  needle, 
and  inject  the  solution. 

Authorities  are  divided  as  to  the  advantage  of  rubbing  the 
spot  vigorously  after  injection.  If  it  bleeds,  a  square  of  adhe- 
sive plaster  may  be  clapped  on  with  instructions  to  remove  it 
in  a  few  hours ;  otherwise  no  dressing  is  required. 

The  reason  for  leaving  the  needle  stuck  in  the  patient's 
buttock  for  a  moment  before  connecting  the  syringe  is  that  its 
point  may  be  in  a  vein,  injection  into  which  would  result  in 
embolus  (see  below).  This  precaution  is  not  essential  for 
soluble  injections  (for  they  do  not  form  emboli),  and  is  neg- 
lected with  apparent  impunity  by  many  who  use  insoluble  in- 
jections.^ Moreover,  embolism  may' occur  in  spite  of  the  great- 
est care  in  this  regard.  Yet  it  is  surely  prudent  to  take  this 
little  precaution. 

Dosage. — It  will  be  found  that  any  of  these  preparations 
may  be  given  to  certain  patients  in  very  high  doses. 

But  equally  good  results,  nay  better  ones,  may  be  obtained 
by  the  ordinary  doses  given  above,  and  an  apparent  toleration . 
on  the  part  of  the  patient  should  never  tempt  ns  to  excessive 
hypodermic  medication.^ — I  know  no  rule  more  important 
than  this — for  excessive  medication  (especially  of  the  insol- 
uble salts)  by  injection  produces  a  distinctly  cumulative  effect. 

1  Indeed,  Berdal  has  seen  emboli  as  often  in  spite  of  this  precaution  as  when 
it  is  not  employed.     Of  late  I  have  omitted  it  with  no  apparent  evil  results. 

2  Thus  I  gave  Case  IV  in  eleven  days  three  injections  of  salicylate,  2  c.c. 
to  the  dose,  while  he  was  taking  six  grains  of  gray  powder  a  day;  and  Case  V 
took  on  January  13th,  0.7  c.c.  of  gray  oil;  on  the  fifteenth,  1.3  c.c;  on  the 
seventeenth,  1.6  c.c;  on  the  nineteenth,  1.3  c.c;  on  the  twenty-second,  2  c.c; 
and  on  the  twenty -fifth,  1.6.  c.c;  in  all,  8.5.  c.c.  (4.25  c.c.  of  pure  mercury)  in 
twelve  days.  This  vigorous  treatment  was  given  only  because  the  oculist 
in  charge  insisted  that  sight  would  be  lost  unless  the  lesion  were  immediately 
controlled.  It  was  controlled,  but  the  patient  was  salivated  for  a  month 
thereafter.     Case  IV,  however,  sufi'ered  no  ill  effects  from  his  treatment. 

Yet  such  cases  as  these  are  exceptional  and  I  now  believe  such  doses  both 
unnecessary  and  harmful.     Even  the  ordinary  dose  of  gray  oil  or  salicylate 


INTRAMUSCULAR    INJECTIONS  179 

The  mercury  continues  to  be  absorbed  for  many  days  after  its 
injection,  and  I  have  twice  (once  in  my  own  practice)  seen 
severe  and  prolonged  salivation  begin  in  the  second  or  third 
week  following  cessation  of  treatment  by  insoluble  injections, 
and  continue  for  many  weeks  thereafter. 

The  injection  method  is  a  wonderfully  effective,  but  a  dan- 
gerous, weapon.  It  should  never  be  employed  carelessly  or  in 
excessive  doses.  //  the  lesion  does  not  yield  to  the  usual  doses, 
the  zuay  to  a  cure  is  not  through  an  increase  in  dose  or  pro- 
longation of  treatment,  but  by  attention  to  hygiene  and  stop- 
ping all  medication.  Case  XXVII  (page  231)  is  a  brilliant 
example  of  the  results  to  be  expected  from  such  a  course. 

Frequency  of  Administration. — For  Routine  Treat- 
ment.— Insoluble  injections  may  be  given,  one  every  two 
weeks,  for  a  year,  or  until  such  time  thereafter  as  there  shall 
have  been  no  symptoms  for  six  months ;  then  one  every  three 
weeks  for  the  second  year ;  then  skip  six  months ;  then  resume 
at  one  a  month  for  six  months.  Relapse  of  symptoms  should 
be  the  signal  for  resumption  of  injections  every  two  weeks  for 
three  months  after  their  cure. 

Soluble  injections  (page  153)  daily  or  every  other  day. 

For  Symptomatic  Treatment. — Insoluble  injections  may 
be  given  once  or  twice  a  week  in  courses  of  not  more  than  three 
or  four  weeks.  Then  an  interval  of  at  least  three  weeks  should 
elapse  before  treatment  is  resumed. 

In  order  to  control  a  lesion  otherwise  unmanageable,  in- 
soluble injections  may  be  given  until  the  lesion  begins  to  yield ; 
then,  especially  if  they  are  distasteful  or  distressing  to  the  pa- 
tient, they  may  be  exchanged  for  some  other  form  of  treat- 
ment. 

sometimes  purges  a  patient  vilely  for  a  day  or  two.     With  injections,  as  with 
internal  medication,  exceptional  persons  can — but  should  not  be  permitted 
to— take  incredibly  large  doses.     Cf.   Klieneberger,  Zeilschr.  /.  klin.  Med., 
1906,  vol.  Ivii. 
14 


i8o  ADMINISTRATION    OF    AlERCURY 

Soluble  injections  may  be  administered  daily  or  every  other 
day  for  as  long  as  three  or  four  weeks.  When  there  is  an 
emergency  requiring  prompt  mercurialization  (e.  g.,  syphilis 
of  the  nervous  system)  I  prefer  to  begin  treatment  with  three 
or  four  daily  injections  of  a  soluble  salt,  and  then  (on  the  next 
day)  begin  a  course  of  insoluble  injections. 

Merits  of  Various  Injections.^ — Among  the  soluble  injec- 
tions, bichlorid  is  generally  preferred,  though  the  benzoate  is 
alleged  to  be  less  painful  and  the  biniodid  more  efficient,  I 
have  personally  given  quite  an  extensive  trial  to  the  bichlorid 
succinamidate,  oxycyanid,  biniodid  (in  Hannam's  and  Lafay's 
sera),  and  enesol,  and  cannot  say  that  I  find  any  great  differ- 
ence in  their  efficiency,  though  I  prefer  the  biniodid  and  iodid 
of  potassium  mixture  (page  175)  because  I  have  found  it  usu- 
ally the  least  painful. 

Among  the  insoluble  injections,  calomel  is  said  to  be  the 
most  efficient,  but  is  too  painful.  My  preference  lies  between 
gray  oil  and  salicylate,  of  which  the  former  is  usually  less 
painful,  the  latter,  perhaps,^  more  efficient. 

The  choice  between  soluble  and  insoluble  injections  is 
largely  a  matter  of  taste.  Both  have  their  champions  for  the 
routine  as  well  as  for  the  symptomatic  treatment  of  syphilis. 
But  since  the  insoluble  preparations  have  been  perfected,  and 
since  the  necessity  for  actually  injecting  them  into  the  muscle 
has  been  generally  understood,  the  vogue  of  soluble  injections 
has  diminished.  None  of  these  injections  is  absolutely  pain- 
less (despite  what  their  votaries  say  to  the  contrary),  and, 
since   soluble   injections   have   to   be   given   every   day   for   a 

1  The  most  extensive  discussions  of  this  subject  are  Levy-Bing,  "Les 
injections  mercurielles,"  Paris,  1902;  also  La  Syphilis,  1905,  vol.  iii,  pp.  28, 
34,  41,  46;   also  /.  Am.  Med.  Ass^n.,  1907,  vol.  xlix. 

^  For  the  past  two  years  I  have  been  tr}'ing  in  vain  to  determine  this  point. 
The  diflerence  in  efficiency  is  ver}^  negligible  in  most  cases  and  Le^^'-Bing 
(arguing  from  scientific  rather  than  from  clinical  premises)  prefers  the  gray  oil. 


INTRAMUSCULAR    INJECTIONS  i8l 

"  course  "  of  ten  to  thirty  injections,  the  pain  caused  by  them 
is  cumulative,  and  in  the  end  may  be  less  tolerable  than  the 
more  severe  ^  but  less  often  repeated  pain  from  insoluble  injec- 
tions. 

A  more  important  distinction  is  this :  Insoluble  injections 
are  the  more  efficient,  and,  since  efficiency  is  the  one  claim  made 
in  favor  of  injections,  this  fact  is  gradually  forcing  insoluble 
injections  to  the  fore. 

On  the  other  hand,  the  action  of  insoluble  injections  is  rela- 
tively slow  to  begin  and  long  continued.  For  this  reason,  as 
already  stated,  it  is  sometimes  wise  to  begin  with  a  few  sol- 
uble injections  to  hurry  on  the  effect  of  the  drug  while  relying 
in  the  main  upon  the  more  efficient  insoluble  injections. 

On  the  other  hand,  we  have  to  consider  the  relatively  grave 
accidents  that  may  result  from  insoluble  injections. 

Disadvantages  of  Injections. — Soluble. — The  disadvan- 
tages of  soluble  injections  are  the  cumulative  pain,  the  rela- 
tive inefficiency,  and  the  necessity  for  daily  visits  to  the  physi- 
cian. . 

Insoluble. — The  disadvantages  of  insoluble  injections  are 
general  and  local. 

The  general  disadvantages  of  insoluble  injections  are  poi- 
soning and  embolism. 

Acute  mercurial  poisoning  may  follow  within  twenty-four 
hours  of  a  single  injection  of  mercury.  It  is  characterized  by 
cramps,  explosive  diarrhea,  depression  of  spirits,  even  fever; 
it  may  last  several  days.  If  the  usual  doses  are  employed 
such  an  attack  follows  the  first  injection  once  in  every  thirty 
or  forty  cases.  It  is  not  prohibitive.  Lessen  the  dose  at  the 
next  injection,  and  thereafter  return  to  the  full  dose. 

Grave  salivation  follows  any  overdosage  with  mercury,  but 
that  following  injections  of  insoluble  mercury  has  two  very 

» Not  always,  but  usually. 


i82  ADMINISTRATION    OF   MERCURY 

annoying  characteristics :  It  is  slow  to  appear  and  slow  to 
disappear.  Thus  I  have  known  two  patients  (as  already 
noted)  to  become  salivated  three  weeks  after  their  last  injec- 
tion. And  in  certain  cases,  such  as  the  one  related  on  page 
178,  the  patient  has  so  much  mercury  under  his  skin  when 
he  becomes  salivated  that  he  keeps  on  absorbing  this  and  pro- 
longs his  salivation  indefinitely.  The  moral  of  which  is : 
Stop  injections  as  soon  as  the  gums  are  touched. 

Embolism  is  due  to  a  drop  of  the  oily  injection  whisking 
off  into  the  general  circulation.  It  is  caused  by  the  perforation 
of  a  vein,  and  is  to  be  guarded  against,  as  far  as  possible,  by 
the  maneuver  already  related.  The  embolism  is  almost  always 
pulmonary;  its  symptoms  may  appear  the  day  after  injection, 
though  they  usually  follow  it  immediately. 

After  a  more  or  less  marked  premonitory  stage  of  slight 
fever  and  malaise,  the  attack  begins  with  a  sharp  pain  in  the 
side,  which  interferes  greatly  with  respiration.  The  tempera- 
ture and  pulse  rise ;  the  patient  is  much  prostrated.  The  physi- 
cal signs  are  those  of  a  circumscribed  pneumonia.  The  whole 
attack  lasts  from  a  few  hours  to  a  week.  Curiously  enough, 
the  injection  which  causes  the  embolism  is  often  remarkably 
painless. 

The  frequency  of  embolism  is  estimated  at  about  one  in  a 
thousand  injections.  I  have  had  but  two  in  my  practice  and 
my  father  one;  this  in  several  thousand  injections.  One  or 
two  fatal  cases  of  mercurial  embolism  have  been  reported.  As 
I  have  seen  it,  embolism  is  a  serious  complication,  quite  seri- 
ous enough  to  prohibit  my  employing  insoluble  injections  in 
all  cases ;  yet  it  is  a  petty  inconvenience  in  comparison  with 
the  benefits  sometimes  to  be  derived  from  their  use. 

The  local  disadvantages  of  insoluble  injections  are  pain, 
induration,  abscess,  sloughing. 

The  pain  varies  greatly.  Soluble  injections  are  painful  for 
one  to  three  days;  during  this  time  they  may  cause  agony. 


INTRAMUSCULAR    INJECTIONS  183 

Insoluble  injections  give  no  immediate  pain  unless  a  nerve  is 
actually  punctured  by  the  needle;  but  in  from  six  to  twenty- 
four  hours  the  spot  begins  to  ache,  and  this  ache  increases  for 
a  day  or  two  longer,  then  gradually  diminishes,  but  may  last 
ten  days  or  more. 

The  first  injection  is  likely  to  hurt  more  than  subsequent 
ones,  but  no  two  of  them  are  alike.  One  may  set  up  an  in- 
tense sciatica,  lasting  a  week,  and  the  next  one  be  almost  pain- 
less. Some  persons  feel  the  pain  much  more  than  others.  In- 
deed, it  is  practically  prohibitive  in  certain  cases.  Yet  I  shall 
always  remember  one  of  my  first  experiences  with  mercurial 
injections.  The  patient  was  a  neurotic  woman;  she  was  los- 
ing the  ala  of  her  nose;  she  had  tried  every  treatment  except 
injections — inunctions,  fumigations,  high  doses  of  iodid,  all 
in  vain.  Small  wonder  that  she  accepted  injections  at  any 
cost.  Yet  every  one  I  gave  her  made  her  vomit  for  hours  and 
kept  her  in  bed  a  day.  But  six  injections  cured  her.  It  was 
worth  the  price. 

On  the  other  hand,  I  have  a  number  of  patients  who  pre- 
fer injections  to  internal  medication  even  for  routine  treat- 
ment, and,  curiously  enough,  one  of  my  most  neurotic  patients 
has  been  on  injections  of  salicylate  for  the  past  year,  and 
asserts  that  they  cause  no  pain  whatever. 

Indurations  may  occur  even  from  insoluble  injections.  I 
have  had  a  patient  come  to  me  with  both  buttocks  a  solid 
indurated  mass  from  injections  of  bichlorid.  As  a  rule,  how- 
ever, even  insoluble  injections  should  leave  no  induration. 
But  if  the  injection  is  not  made  deep  enough,  or  if  any  of  the 
injected  fluid  leaks  back  along  the  track  of  puncture  a  red, 
tender,  edematous  swelling  in  the  subcutaneous  tissue  results. 
After  several  weeks  this  subsides,  leaving  an  induration,  some- 
what sensitive  to  pressure,  and  over  which  the  skin  may  remain 
for  a  long  time  bluish  and  glossy. 

Such  reactions  are  rare.      They  are  apparently  unavoid- 


i84  ADMINISTRATION    OF   MERCURY 

able  in  certain  fat,  soft  subjects,  but  they  can  almost  always 
be  prevented  by  proper  technic.  Not  one  in  ten  of  my  injec- 
tions cause  them. 

In  the  muscle  itself  the  injection  leaves  a  small  induration 
which  may  be  pierced  by  the  needle  at  the  time  of  a  subse- 
quent injection.  A  second  charge  may  be  shot  into  this  mass 
without  causing  any  untoward  reaction. 

Abscess  and  gangrene  are  usually  due  to  dirt  or  careless- 
ness. Neither  accident  has  occurred  in  my  practice;  yet  I 
believe  there  must  have  been  necrosis,  if  not  slight  suppura- 
tion, in  some  of  the  indurated  lumps  I  have  caused.  Such 
suppuration  may  be  due  to  the  debilitated  condition  of  the 
patient. 

A  few  cases  of  gangrene  have  been  reported  (Nicolsky  ^) 
as  caused  by  the  occlusion  of  an  artery  by  the  injection. 
Though  extremely  rare,  such  an  accident  could  neither  be  fore- 
seen nor  avoided. 

Advantages  of  the  Method. — Such  hideous  possibilities, 
were  they  not  extremely  remote,  would  be  enough  to  deter  one 
from  using  insoluble  injections.  In  my  office  practice  I  admin- 
ister from  four  to  a  dozen  injections  of  insoluble  mercury  a 
week,  and,  but  for  two  embolisms,  a  few  cases  of  salivation 
and  an  occasional  sharp  local  reaction,  I  have  had  no  acci- 
dents, and  others  who  use  the  injections  on  thousands  of  cases 
in  their  clinical  practice  report  equally  good  results. 

Yet  even  such  relative  immunity  from  grave  accidents 
would  not  warrant  the  use  of  this  method  were  not  its  results 
superlatively  good.  They  are  no  less.  Insoluble  injections 
will  not,  to  be  sure,  cure  every  lesion  of  syphilis;  but  where 
mercury  will  work  at  all,  these  injections  are  always  as  effi- 
cient as  any  other  method,  and  often  much  more  so. 

I  have  seen  lesions  yield  to  them  after  resisting  every  other 


1  Bull,  de  la  soc.  de  derm,  et  syph.,  1906,  vol.  xvii,  p.  42- 


INUNCTION  185 

form  of  treatment,  even  soluble  injections.  I  have  met  but 
one  exception,  a  palmar  syphilid,  that  yielded  better  to  fumi- 
gations than  to  injections. 

Such  being  the  case,  insoluble  injections  are  surely  the 
method  of  choice  for  the  cure  of  the  lesions  of  syphilis  unless 
they  be  readily  curable  by  other  means  or  the  patient  too  sensi- 
tive to  bear  the  pain  of  injection. 

Let  us  state  the  case  another  way.  Most  lesions  are  emi- 
nently curable  without  injections,  and  to  certain  patients  the 
pain  of  injections  is  almost,  if  not  quite,  unbearable. 

In  most  instances,  therefore,  the  physician  may  select  the 
method  of  treatment  he  pleases;  in  a  certain  few  he  is  driven 
to  use  injections  by  the  failure  of  all  else. 

INUNCTION 

Preparations  Employed. — The  officinal  blue  ointment 
(ung.  hydrargyri)  can  be  improved  by  the  substitution  of  one 
of  the  proprietary  ointment  bases,  such  as  resorbin  or  vasogen. 
These  are  less  greasy  and  odoriferous.  One  part  of  mercury 
may  be  rubbed  into  one  or  more  parts  of  the  base,  or  the  prepa- 
ration may  be  obtained  ready  made  in  twenty  per  cent  and 
fifty  per  cent  strengths.  Put  up  in  dram  capsules  (one  for 
each  rub)  they  are  convenient  to  carry  about. 

Another  new  preparation  is  calomelol  ointment,  white  in 
color,  put  up  in  graduated  glass  tubes,  two  of  the  "  marks  " 
to  be  used  for  each  rub.  It  is  cleaner  than  the  blue  oint- 
rnent,  and  seems  to  be  about  as  efficient  and  somewhat  less 
irritating. 

Mercurial  plasters  and  mercurial  shirts  are  no  longer  gen- 
erally employed  in  the  constitutional  treatment  of  syphilis, 
though  the  plasters  are  sometimes  used  for  a  local  effect. 

The  Technic. — The  best  method  is  that  employed  at  the 
Hot  Springs.     The  patient  takes  a  hot  soap-and-water  bath, 


l86  ADMINISTRATION    OF   MERCURY 

is  well  rubbed  down  with  alcohol,  and  then  is  ready  for  his 
inunction.  He  sits  astraddle  a  chair  with  his  face  toward  the 
back,  his  arms  folded  upon  it  and  his  chin  resting  upon  his 
arms.  An  attendant  now  rubs  in  broadly  and  with  a  vigorous 
circular  motion  of  the  hand  over  the  entire  back  a  given  quan- 
tity of  mercurial  ointment,  generally  one  dram  at  a  rub.  The 
friction  continues  for  twenty  minutes.  (To  prevent  mercurial- 
ization  the  frictioner  may  protect  his  hand  with  a  rubber 
glove.)  The  ointment  thus  rubbed  in  is  left  upon  the  back, 
and  the  patient  puts  on  first  a  thin  gauze  undershirt  (which 
he  wears  a  week  as  a  "mercurial"  shirt),  and  over  this  his 
ordinary  undershirt  and  customary  clothing.  On  the  follow- 
ing day  the  patient  takes  another  hot  soap-and-water  bath,  is 
thoroughly  washed,  rubbed  with  alcohol,  and  then  takes  an- 
other friction  as  on  the  previous  day,  resuming  his  mercurial 
shirt. 

In  case  the  patient  has  to  do  his  own  rubbing  he  cannot 
reach  his  back,  and  as  no  other  part  of  the  body  is  covered 
with  skin  sufficiently  thick  to  bear  daily  rubs,  he  is  obliged 
to  shift  from  place  to  place.  The  hot  bath,  the  alcohol  rub, 
and  the  mercurial  shirt  are  employed  as  in  the  above-described 
system,  and  the  rubs  are  made  in  the  following  regions  on 
successive  days : 

1.  Right  arm  and  forearm,  internal  aspect. 

2.  Left  arm  and  forearm,  internal  aspect. 

3.  Right  thigh,  internal  aspect. 

4.  Left  thigh,  internal  aspect. 

5.  Right  side  of  thorax  and  loin.  " 

6.  Left  side  of  thorax  and  loin. 

7.  Abdomen. 

The  purpose  in  thus  distributing  the  course  is  to  make  it 
occupy  an  even  week.  Hairy  subjects  may  have  to  modify  the 
plan. 

The  ointment  must  be  rubbed  into  the  skin  until  every  bit 


INUNCTION  187 

of  greasiness  has  disappeared.  This  takes  about  twenty  min- 
utes, and  is  a  duty  the  patient  is  inclined  to  shirk. 

Duration  of  Treatment. — Inunctions  are  usually  given 
daily  in  courses  of  two  to  four  weeks.  With  the  ordinary 
dose  (i  dram  (4  gm.)  of  fifty  per  cent  blue  ointment)  the 
patient  is  usually  slightly  salivated  in  two  or  three  weeks. 
When  salivation  occurs  the  rubs  must  be  suspended. 

Merits  of  Inunctions. — In  efficacy  inunction  ranks  below 
injection  and  fumigation.  In  convenience  it  may  rank  higher 
than  either,  in  that  it  can  be  performed  by  the  patient  himself. 
But  the  dosage  is  uncertain,  for  we  do  not  know  how  much 
mercury  is  absorbed  by  the  skin  (or  whether  the  absorption  is 
not  chiefly  by  inhalation  of  the  mercury  that  evaporates  from 
the  surface  of  the  body  ^ ) ,  and  very  few  patients  rub  in  the 
ointment  thoroughly. 

But  the  chief  objection  to  inunction  comes  from  the  patient. 
The  treatment  is  dirty  and  disgusting;  it  often  irritates  the 
skin,  and  may  even  provoke  a  local  eczema;  it  is  tedious  in 
the  taking. 

For  these  reasons  I  find  that  when  I  ask  a  patient  to  choose 
between  inunction  and  injection  he  almost  invariably  selects 
the  latter.  And  unless  he  is  oversensitive  to  injections  I  much 
prefer  he  should. 

Actually  I  employ  inunctions  very  rarely;  only  when  a 
patient  needs  vigorous  treatment,  and  cannot  or  will  not  take 
injections  or  fumigations.  But  many  physicians  employ  them 
frequently,  even  for  the  routine  treatment  of  the  disease.  The 
choice  is  largely  a  matter  of  taste. 

"  This  question  has  never  been  absolutely  settled;  but  it  would  seem  that 
with  the  ordinaiy  method  of  inunction,  fully  as  much  mercury  is  absorbed  by 
the  skin  as  is  inhaled. 


l88  ADMINISTRATION   OF   MERCURY 

FUMIGATION 

Salts  Employed. — The  salts  of  mercury  most  suitable  for 
fumigation  are  calomel  and  the  black  oxid.  The  former  is 
the  more  popular,  but  I  prefer  the  latter  (which  is  less  irri- 
tating). The  dose  of  calomel  is  gr.  xx  (1.3  gm.),  of  the 
black  oxid,  oij  to  ijss  (8  to  10  gm.).  The  fumigations  are 
usually  repeated  twice  a  week. 

The  Technic. — If  the  fumigation  cannot  be  taken  at  a  bath 
establishment,  it  may  be  taken  at  home  with  the  aid  of  the 
following  apparatus:  a  piece  of  tin,  10  X  3I  inches,  bent  to 
a  right  angle  at  3  inches  (more  or  less)  from  each  end;  a 
spirit  lamp  or  Bunsen  burner;  a  large  pan  of  boiling  water; 
a  chair;  a  couple  of  large  blankets  or  a  vapor-bath  cabinet. 
The  patient  strips  and  sits  on  a  chair  surrounded  by  the  blank- 
ets or  the  cabinet,  with  his  head  out.  Under  the  chair  are 
placed. the  pan  of  steaming  water  and  beside  it  the  spirit  lamp 
covered  by  the  bent  tin,  upon  which  the  mercury  is  spread. 

As  soon  as  the  body  becomes  warm  and  moist  the  spirit 
lamp  is  lighted,  and  the  salt  begins  to  volatilize.  After  fifteen 
minutes  the  heat  usually  becomes  unbearable;  the  lamp  may 
then  be  extinguished,  but  the  patient  should  sit  in  the  mer- 
curial fumes  ten  minutes  longer.  Then  he  arises,  wraps  him- 
self in  a  blanket,  and  lies  down  until  he  is  cool.  He  should 
not  take  a  bath  until  the  following  day. 

Calomel  fumes  are  often  irritating  to  the  mucous  mem- 
branes, and  should,  therefore,  not  be  inhaled;  but  if  the  black 
-oxid  is  used,  the  patient  may  take  an  occasional  whiff  with 
impunity  and  perhaps  with  some  benefit. 

Let  him  also  take  care  not  to  burn  himself  to  death. 

Merits  of  the  Method. — The  difficulties  surrounding  fumi- 
gation are  many.  Very  few  patients  will  spend  the  time  and 
trouble  to  take  their  baths  at  home,  and  I  know  of  no  bath  estab- 
lishment in  New  York  where  they  are  properly  given.    Yet  the 


INTRAVENOUS    INJECTION  189 

method  is  not  painful  like  injection  (and  usually  not  quite 
so  efficacious),  more  powerful  and  more  cleanly  than  inunction. 
The  danger  of  salivation  is  the  same  as  with  injections. 

I  use  it  quite  frequently  and  with  very  satisfactory  results 
in  the  most  stubborn  cases. 

INTRAVENOUS    INJECTION 

Since  its  introduction  by  Bacelli  this  method  of  adminis- 
tering mercury  has  been  taken  up  repeatedly  by  various  inves- 
tigators in  the  hope  that,  in  spite  of  its  manifest  perils,  it 
might  prove  peculiarly  useful.  But  no  great  virtues  have  been 
found  in  it.  The  salt  thus  introduced  into  the  circulation  has 
a  more  immediate  action,^  but  also  a  briefer  period  of  activity 
than  when  injected  into  the  muscle.  But,  barring  accidents, 
intravenous  injection  is  entirely  painless.  Hence  it  has  the 
vices  of  the  soluble  injections,  less  their  pain,  and  would  be 
advantageous  only  for  the  production  of  an  instant  mercurial 
effect  in  a  patient  so  sensitive  as  not  to  bear  any  form  of  intra- 
muscular injections — a  most  improbable  combination,  and  one 
I  have  not  yet  encountered. 

Solutions  Employed. — Bichlorid. — This  salt,  though 
subject  to  the  criticism  that  it  coagulates  albumin,  was  em- 
ployed by  Bacelli  and  has  been  more  used  than  any  other. 

Bacelli's  formula  is : 

Hydrarg.  bichlorid i   gm. ; 

Sod.  chlorid 3  gm. ; 

Aq.  destillat i  ,000  gm. 

Inject  I  c.c.  daily. 

Other  Salts. — Barthelemy  and  Levy-Bing  have  also 
employed  the  oxycyanid  (1:1,000)  and  the  biniodid  (i,  2, 
or  3  :  1,000).     They  prefer  the  last. 

•  Berdal  denies  this. 


190 


ADMINISTRATION    OF    MERCURY 


Technic. — Abadie,  one  of  the  few  avowed  partisans  of  this 
method,  advises  the  following  technic : 

1.  He  employs  a  syringe  whose  barrel  and  piston  are  both 
of  glass  (thus  assuring  absolute  freedom  from  specks  of  dirt) 
and  a  fine  needle.     These  he  sterilizes  by  boiling. 

2.  He  employs  the  oxycyanid  (1:1,000),  injects  i  c.c. 
every  other  day  for  twenty  days  (10  injections)  ;  then,  after 
an  interval  of  a  fortnight,  resumes  this  twenty-day  course  as 
often  as  necessary. 

3.  "  Before  injecting  I  distend  the  veins  at  the  elbow  by 
a  ligature  about  the  arm.  I  choose  the  (most  prominent) 
vein  (at  the  elbow)  and,  after  careful  antisepsis,  insert  the 
fine  needle  gently  and  obliquely  into  the  center  of  the  vein. 
The  entrance  of  the  needle  into  the  vein  imparts  a  character- 
istic sensation.^  The  patient  does  not  feel  the  least  distress. 
The  injection  is  made  slowly  after  removal  of  the  ligature. 
An  antiseptic  collodion  dressing  is  applied  and  the  patient 
returns  to  his  work  "  (Abadie). 

Complications. — The  method  appears  to  be  less  difficult 
and  dangerous  than  one  would  expect.  Such  local  incon- 
veniences as  ecchymosis,  periphlebitis,  nodosities,  and  subcu- 
taneous edema  would  be  pardonable  were  there  any  great 
advantage  in  the  method;  but  this  does  not  appear  to  be 
the  case. 

OTHER    METHODS    OF    ADMINISTRATION 

Intratracheal  Injection. — Described  by  Landis.- 
Administration   per   Rectum.  —  Andry  ^   has   successfully 
employed  suppositories  of  gray  oil,  each  containing  gm.  0.02 

1  Marcus  and  Wi elan der  (Archiv  f.  Dermal,  u.  Syph.,  1906,  vol.  Ixxix,  p.  213) 
aspirate  a  drop  of  blood  to  be  sure  they  are  in  the  vein.  They  give  as  many 
as  thirty  daily  injections  of  bichlorid. 

^  Gaz.  des  hop.,  1905,  April. 

^  Ann.  de  dermal,  el  syph.,  1905,  vol.  vi,  October. 


COMPARISON    OF   VARIOUS   METHODS  191 

to  0.04  of  metallic  mercury.  He  recovered  mercury  from  the 
urine,  found  that  one  suppository  a  day  for  twenty-five  days 
in  the  month  was  perfectly  well  tolerated  for  an  indefinite 
period,  and  believes  that  the  action  of  the  mercury  upon  lesions 
is  as  efficient  as  when  it  is  administered  by  the  mouth,  while 
being  free  from  every  inconvenience. 

COMPARISON   OF   VARIOUS   METHODS 

In  the  preceding  paragraphs  I  have  endeavored  to  make 
clear  my  own  preferences,  and  the  reasons  for  them,  while 
showing  due  deference  to  those  who  differ  from  my  views. 
There  are  many  excellent  methods  of  treating  syphilis,  and, 
inasmuch  as  every  method  finds  its  application  somewhere — 
inasmuch  as  I  myself  employ  them  all — it  is  often  a  matter 
of  no  great  moment  what  method  is  employed  so  long  as  it  is 
efficient  and  pleases  the  patient.  My  only  plea  is  that  internal 
medication  be  employed  as  much  as  possible  for  the  conven- 
ience of  the  patient,  and  that  hypodermics  be  fearlessly  used  in 
stubborn  cases  or  in  cases  where  an  immediate  effect  is  re- 
quired  (e.g.,  brain  syphilis). 

The  relative  merits  of  the  various  methods  of  administer- 
ing mercury  may  be  summed  up  as  follows : 

For  Efficiency.  —  Insoluble  injection,  soluble  injection, 
fumigation,  inunction,  internal  medication. 

For  Comfort. — Internal  medication  (or  insoluble  injec- 
tion or  soluble  injection) — then  the  others  in  different  order 
for  each  case. 

In  the  routine  treatment  comfort  should  always  be  consid- 
ered first ;  in  the  cure  of  symptoms  it  may  have  to  hozv  before 
efUciency. 


CHAPTER    XIV 
THE  lODIDS— MIXED   TREATMENT 

When  we  speak  of  the  iodids,  we  think  of  the  iodid  of 
potassium.  This  drug  is  worth  more  than  all  the  others 
together.  Occasionally  the  patient  is  so  susceptible  to  its  in- 
fluence that  some  substitute  has  to  be  employed,  but  no  effort 
should  be  spared  to  make  the  patient  digest  potassium  iodid, 
so  infinitely  superior  is  it  to  all  the  other  remedies  claiming  to 
be  "  just  as  good." 

Therapeutic  Indications. — Iodids  are  indicated  in  the 
treatment  of : 

1.  Tertiary  lesions. 

2.  Neuralgic  or  painful  lesions,  especially  the  pains  of  early 
secondary  periostitis,  arthritis,  headache,  etc. 

3.  Cases  in  which,  on  account  of  idiosyncrasy  or  severe 
nephritis,  mercury  cannot  be  borne. 

Unfortunately,  though  grave  toxemia  from  iodid  is  rare, 
mild  inconveniences  are  extremely  common.  It  is  therefore  es- 
sential to  understand  the  toxic  effects  of  the  drug  and  how  to 
combat  them. 


IODID   POISONING    (lODISM) 

Iodid  poisoning  shows  itself  in  many  forms.     Among  the 
commoner  ones,  often  occurring  in  conjunction,  are: 

1.  The  metallic  taste. 

2.  Coryza. 

192 


lODID    POISONING    (lODISM)  193 

3.  Indigestion. 

4.  Acne. 

Among  the  rarer  forms  may  be  mentioned : 

5.  Various  skin  lesions. 

6.  Toxemia  of  the  nervous  type. 

7.  Sahvation  and  congestion  of  the  sahvary  glands. 

8.  Neuralgia. 

9.  Localized  edema. 

10.  Epistaxis,  urethritis,  albuminuria. 

Metallic  Taste. — The  metallic  taste,  as  though  the  pa- 
tient had  a  copper  cent  in  his  mouth,  is  usually  the  first  symp- 
tom of  iodic  poisoning.  Many  patients  state  that  every  dose 
of  the  drug  leaves  this  taste  in  the  mouth. 

Iodic  Coryza. — This  resembles  a  common  cold  in  its 
milder  forms;  but  when  severe  simulates  the  most  violent. hay 
fever ;  the  "  head  is  stopped  up " ;  the  eyes  and  nose  run 
copiously. 

A  still  more  violent  phase  is  the  iodic  grippe,  characterized 
by  sudden  onset  of  the  most  violent  naso-pharyngeal  catarrh, 
fever,  intense  headache,  and  utter  prostration. 

Happily,  these  various  phenomena  do  not  succeed  one  an- 
other in  order  of  intensity.  The  average  patient,  having 
reached  an  iodic  coryza,  or  an  "  iodic  hay  fever,"  goes  no  fur- 
ther. Let  the  iodid  be  increased,  and  he  actually  passes 
through  this,  and  at  the  higher  dose  shows  none  of  the 
phenomena  produced  by  lesser  amounts.  Yet,  let  the  iodid 
be  discontinued  for  a  few  weeks,  and,  on  resuming  its  use, 
the  patient  has  to  go  through  precisely  the  same  misery 
before  reaching  the  higher  dose  at  which  he  no  longer 
suffers. 

Iodic  grippe  (if  it  occurs  at  all)  is  usually  caused  by  the 
very  first  doses  of  the  drug.  It  subsides,  as  it  arises,  almost 
simultaneously  (on  withdrawal  of  the  iodid),  and  is  evidence 
of  a  peculiar  sensibility. 


194  THE    lODIDS— MIXED    TREATMENT 

Indigestion. — This  is  the  most  annoying  of  the  com- 
moner forms  of  iodic  poisoning,  since  it  cannot  very  well  be 
borne  for  any  length  of  time,  nor  can  it,  like  the  coryza,  be 
lived  down. 

This  indigestion  may  merely  amount  to  a  little  abdominal 
discomfort  and  a  disgust  for  food.  If  the  remedy  is  pushed, 
the  patient's  digestion  goes  all  to  pieces;  he  is  nauseated,  has 
cramps  and  diarrhea,  and  the  iodid  has  to  be  stopped.  If  it  is, 
nevertheless,  brutally  pushed,  the  patient's  digestion  may  be 
damaged  for  years  or  forever. 

Acne. — Pustular  acne,  usually  upon  the  face,  neck,  shoul- 
ders, back,  or  buttocks,  is  extremely  common.  The  eruption 
comes  out  in  crops.  The  pustules  may  attain  the  proportions 
of  little  boils.  Though  annoying,  the  eruption  is  bearable. 
No  treatment  appears  to  influence  it;  but  the  pustules  should 
be  left  undisturbed.  The  more  they  are  pinched  and  squeezed 
the  longer  they  last.  I  have  sometimes  thought  that  combin- 
ing the  acetate  with  the  iodid  lessened  the  acne  outcrop. 

Other  Skin  Lesions. — The  rare  skin  eruptions  due  to 
iodism  are  erythema,  which  may  be  papular,  commonly  occur- 
ring upon  the  nose,  cheeks,  and  forehead,  and  may  become 
eczematoid;  papules  or  tubercles  (very  rare)  ;  purpura,  usually 
affecting  the  legs  and  occurring  in  the  old  and  debilitated; 
hullce,  which  usually  occur  on  the  face  and  extremities,  and 
may  be  so  umbilicated  and  so  numerous  as  to  suggest  variola; 
a  pustulo-critstaceoiis  dermatitis  (simulating  syphilis),  and 
various  combinations  of  these  varieties. 

Toxemia. — Iodic  nervous  toxemia  occurs  under  two  types : 
In  the  acute  form,  due  to  a  short  course  of  heroic  medication, 
the  patient  is  overwhelmed  by  the  drug  and  lies,  stupidly 
drooling,  unable  to  take  nourishment,  perhaps  absolutely  un- 
conscious. Yet  on  stopping  the  drug  the  patient  is  up  and 
alx)ut  in  a  fortnight  (see  Case  VI,  page  20). 

In  the  chronic  form,  due  to  prolonged  administration  of 


METHOD    OF    ADMINISTRATION    AND    DOSAGE  195 

large  doses,  the  symptoms  are  commonly  mistaken  for  those 
of  syphilis  of  the  nervous  system  with  the  disastrous  result  of 
encouraging  the  use  of  more  and  more  iodid.  I  have  seen 
several  patients  long  under  treatment  by  iodid  for  severe  nerv- 
ous lesions  due  to  syphilis  gradually  become  anemic,  restless, 
nervous,  despondent,  tremulous,  unable  to  eat,  and  apparently 
too  weak  to  do  any  work.  I  have  known  two  of  them  to  give 
up  work,  and  one  of  them  prepare  to  die.  One  could  not  sign 
his  name,  so  weak  and  unsteady  was  he,  and  yet  both  recov- 
ered in  a  few  w'eeks  after  leaving  off  the  iodid,  going  away 
from  town,  and  resorting  to  general  tonic  measures. 

It  is  to  prevent  the  occurrence  of  such  mishaps  that  syphi- 
lis of  the  nervous  system  is  nowadays  treated  by  intermittent 
courses  of  iodid. 

Salivation. — Salivation  due  to  iodid  is  never  so  severe 
as  the  true  mercurial  salivation,  nor  is  it  accompanied  by  any 
grave  lesions  of  the  mouth.  Enorinous  swelling  of  the  sali- 
vary glands  may  be  caused  by  a  single  dose  of  iodid. 

Neuralgia. — Distressing  facial  neuralgia  may  be  the  first 
evidence  of  iodism.     Pains  elsewhere  are  rare. 

Edema. — Edema,  localized  about  the  face,  or  a  much  more 
grave  edema  of  the  upper  air  passages,  threatening  asphyxia- 
tion, are  fortunately  extremely  rare. 

Other  Lesions. — Urethritis  and  albuminuria  and  epis- 
taxis  may  be  caused  by  iodism.     They  are  unimportant. 

METHOD    OF    ADMINISTRATION   AND    DOSAGE 

The   susceptibility    of  various  patients   to    iodism    diifers 

widely.     I  have  seen  a  single  dose  of  iodid  of  potash  (gr.  v) 

cause  the  submaxillary  glands  to  swell  to  the  size  of  pigeon's 

eggs,  and  have  record  of  several  cases  of  facial  edema  and 

iodic  erythema   or   urticaria   following  a   similar   dose.      My 

father  has   recorded   the   experiences  of  two  physicians,   one 
15 


196  THE    lODIDS— MIXED    TREATMENT 

of  whom  "  at  one  time  could  not  touch  his  tongue  to  the 
moistened  cork  of  a  bottle  containing  an  iodid-of-potash 
solution  without  feeling  the  effects  for  a  day  upon  the  mu- 
cous membrane  of  his  nose " ;  while  the  other  "  experi- 
enced mild  symptoms  of  iodism  if  the  tincture  of  iodin  touched 
his  skin." 

But  such  cases  are  most  exceptional.  As  a  ride,  the  metallic 
taste,  mild  snuffles,  and  acne  may  be  expected  at  a  dose  of  gr. 
X  to  gr.  XXV  (0.6-1.6  gm.)  three  times  a  day,  and  indigestion 
at  double  these  doses.  On  the  other  hand,  the  patient  may 
take  an  ounce  (30  gm.)  a  day  with  no  inconvenience  except 
a  strong  metallic  taste. 

Yet  there  is  always  some  doubt  at  first  as  to  how  well  the 
patient  will  digest  the  iodid,  and,  accordingly,  its  administra- 
tion is  always  surrounded  with  many  precautions. 

The  One  Hundred  Per  Cent  Solution. — The  preparation 
commonly  employed  is  the  "  saturated  solution  "  of  iodid  of 
potassium  given  in  drop  doses.  But  there  are  two  terms  here 
which  may  be  misinterpreted :  What  is  a  "  saturated  solii- 
tion  "  ?  what  a  "  drop  dose  "  ? 

If  you  simply  prescribe  "  a  saturated  solution,"  the  phar- 
macist may  take  you  at  your  word  and  compound  a  mixture 
containing  one  hundred  and  twenty  per  cent  (or  more)  of 
potassium  iodid.  This  is  precisely  what  you  do  not  wish.  You 
wish  a  one  hundred  per  cent  solution.  To  avoid  error,  there- 
fore, always  write  as  follows : 

I^   Potass,  iodid oj    (30  gm.)  ; 

Aquae   q.  s.  ad  oj    ( ad  30  c.c. ) . 

The  Minun  Drop. — In  the  second  place,  the  droppers  of 
commerce  vary  in  size  as  well  as  shape,  and  none  of  them  drop 
minims.  Therefore,  the  drug  must  be  dispensed  in  a  dropper 
bottle  (which  drops  minims)  or  accompanied  by  a  minim 
graduate.     The  dropper  bottle  is  better  adapted  to  small  doses, 


METHOD    OF   ADMINISTRATION    AND    DOSAGE         197 

the  graduate  to  large  ones.  The  patient  will  find  it  conven- 
ient to  measure  out  in  the  morning  such  doses  as  he  is  to  take 
during  the  day  while  away  from  home,  and  carry  them  about 
in  small  vials  or  in  a  graduated  bottle. 

It  may  be  more  convenient  to  use  tablets  (gr.  v)  of  iodid, 
but  the  solution  seems  to  be  less  poisonous. 

The  Time  of  Administration. — Iodid  is  better  borne  if  ad- 
ministered on  a  relatively  empty  stomach.  Three  hours  after 
meals  (e.  g.,  at  11  a.m.,  4  and  9  p.m.)  is  the  ideal  time.  But 
this  is  so  inconvenient  an  arrangement  that  I  have  most  of 
my  patients  take  it  on  arising,  half  an  hour  before  lunch,  and 
on  retiring  (or  a  fourth  dose  may  be  inserted  half  an  hour 
before  dinner).     But  many  persons  can  take  it  at  any  time. 

The  Dilution. — The  iodid  must  always  be  diluted.  The 
administration  of  an  undissolved  tablet  will  give  most  people 
heartburn  for  hours. 

As  far  as  possible,^  one  should  make  it  a  rule  to  dissolve 
no  more  than  oss  (2  gm.)  of  the  salt  in  a  single  tumblerful  of 
fluid,  while  even  the  smallest  dose  merits  at  least  half  a  tum- 
blerful. 

The  Diluent. — If  the  patient  can  digest  milk,  this  is  much 
the  best  diluent,  gaseous  waters  are  the  second  choice,  plain 
water  the  third  choice.  For  a  continuous  course,  it  is  well  to 
suggest  an  occasional  change  of  vehicle. 

Any  other  fluid,  such  as  coffee  or  tea,  may  be  employed 
if  the  patient  prefers,  and  if  it  may  be  drunk  in  sufficient 
quantity  to  effect  the  desired  dilution. 

Prevention  of  lodism.  —  So  common  are  the  annoyances  of 
iodism  that  innumerable  remedies  have  been  devised  to  prevent 
them.     These  may  be  divided  into  two  classes : 

1.  Methods  of  taking  potassium  iodid. 

2.  Substitutes  for  potassium  iodid. 

«  The  limit  with  high  doses  being  the  number  of  glasses  of  fluid  a  patient 
can  drink. 


198  THE    lODIDS— MIXED    TREATMENT 

Methods  of  Taking  Potassium  Iodid. — Little  can  be 
done  beyond  taking  the  drug  well  diluted,  not  during  or  after 
meals,  and  in  a  suitable  medium  (see  above). 

The  taste  of  the  drug  may  be  disguised  by  syrup  of 
orange  peel  (syr.  aurantii  cort.),  or  by  a  few  drops  of  lemon 
juice.  Milk,  cofifee,  and  carbonated  waters  also  disguise  the 
flavor. 

In  order  to  aid  the  digestion  of  iodids,  ten  drops  of  dilute 
hydrochloric  acid  after  meals  is  often  helpful.  The  combina- 
tion of  Tr.  nucis  vomicae  (or  of  tincture  of  belladonna  or  of 
arsenic)  with  each  dose  of  iodid  is  well  spoken  of;  but  they 
have  been  of  no  use  at  my  hands. 

A  favorite  English  prescription  is : 

^   Potass,  iodid.,  1 

Sodii  iodid.,       \ aa     gr.  cc.    (aa   14  gm.)  ; 

Amonii  iodid.,  j 

Tr.  nucis  vomicae oij    (8  gm.)  ; 

Infus.  quassse ad  oiv   (ad   130  gm.). 

M. 

S.  Ten  minims  t.i.d.,  and  increase  arithmetically  (20 
t.i.d.  on  the  morrow,  then  30,  etc.). 

Some  patients  prefer  this  to  plain  iodid,  yet,  as  a  rule,  it  is 
no  better. 

The  best  way  of  all  is  to  put  the  patient  in  the  best  pos- 
sible hygienic  surroundings,  on  a  light,  simple  diet,  give  the 
iodid  in  small  doses  at  first,  and  increase  the  dose  slowly. 
If  mild  iodic  acne  or  coryza  occurs,  the  dose  should  be 
still  further  increased,  and  the  patient  will  doubtless  pass 
through  it. 

Iodid  of  potassium  may  be  administered  per  rectum :  3ij-iv 
(8-16  gm.)  in  ovi  (200  cc.)  of  peptonized  milk.  But  this 
method  is  not  very  efficient,  and  can  be  used  for  only  a  short 
time.     The  iodid  is  not  suitable  for  hypodermic  medication. 


METHOD    OF    ADMINISTRATION    AND    DOSAGE  199 

Doevenspeck  ^  has  used  daily  intravenous  injections  of  five  per 
cent  solution  (injecting  2  c.c). 

Substitutes  for  Potassium  Iodid. — This  is  a  weary- 
tale.  Each  year  brings  new  iodid  compounds  "  quite  as 
good."  A  few  scientists  report  wonderful  results  from  their 
use — and  they  die  a  natural  death. 

Sodium  iodid  is  about  half  as  strong  as  potassium  iodid. 
It  has  to  be  dissolved  in  twice  its  weight  of  water,  and  thus 
forms  a  fifty  per  cent  solution.  Hence  to  get  the  same  effect, 
four  times  as  much  of  this  solution  is  required  as  of  one  hun- 
dred per  cent  potassium  iodid.  And  even  at  that  it  is  not  as 
efificient,  though  somewhat  less  poisonous.-  I  very  rarely 
use  it. 

Ammonium  iodid,  calcium  iodid,  strontium  iodid,  iodid  of 
starch,  and  iodoform  are  no  longer  employed. 

Tincture  of  iodin  is  too  feeble  to  be  of  service. 

Syrup  of  hydriodic  acid  is  a  mild  tonic.  It  is  useless  for 
vigorous  treatment. 

Sajodin  is  highly  spoken  of  by  Fischer  and  Mering,^ 
Roscher,^  and  Mayer.^  It  is  a  colorless,  tasteless  powder  in- 
soluble in  water.  It  is  said  to  contain  twenty-six  per  cent 
iodid.  Dose,  in  powder  or  capsule,  the  same  as  that  of  potas- 
sium iodid,  which  it  is  said  to  equal  in  effect  without  produc- 
ing any  poisoning.  It  is  therefore  to  be  used  by  patients  who 
cannot  take  the  potassium  salt.    I  have  not  tried  it. 

lothion  ^  is  a  form  of  iodin  alleged  to  be  absorbable  by  the 
skin,  and  thus  sparing  the  stomach.  Two  to  three  c.c.  are 
painted  upon  the  normal  skin  daily. 


»  Therap.  der  Gegenuart,  1905,  vol.  xlvi,  No.  12.  • 

^  Cf.  Distefano,  Rijorma  tried.,  1905. 
^  Med.  Klinik.,  1906,  No.  7. 
*  Dermal.  Zeitschr.,  1906,  No.  3. 

«  Lipschutz,  Arch,  jiir  Derm.  u.  Syph.,  1905,  vol.  Ixxiv,  p.  265;  Ravosini  and 
Hirsch,  ibid.,  p.  295;  Wesenberg,  ibid.,  p.  301. 


200  THE    lODIDS— MIXED    TREATMENT 

Among  the  other  modern  organic  compounds  I  have  found 
no  help.  One  of  them  looks  like  brick  dust  and  is  quite  as 
active. 

lodipin  and  Lipiodol. — lodipin  for  internal  administration 
contains  ten  per  cent  iodin  in  oil ;  a  twenty-five  per  cent  solu- 
tion is  used  for  intramuscular  injection  (dose,  oss—i^  2-4 
gm.).  Lipiodol  is  a  similar  but  stronger  preparation;  it  con- 
tains forty  per  cent  iodin.  Both  of  these  preparations  may  be 
used  freely  by  injection.  lodipin  is  employed  constantly  at 
Aachen.  I  have  not  tried  it  fairly;  but  have  used  the  lipiodol 
in  doses  of  oss-iss  (2—6  gm. ).  These  enormous  doses  of  a 
thick  oil  ^  when  plunged  into  the  gluteal  muscles  actually  cause 
far  less  pain,  on  the  average,  than  any  injection  of  mercury  I 
know.  A  distinct  iodic  efifect  may  be  obtained  by  these  injec- 
tions, but  I  have  yet  to  prove  that  they  are  as  effective  as 
potassium  iodid  by  mouth.  In  case  of  gastric  intolerance, 
however,  they  are  valuable. 

Dose. — What  is  the  dose  of  potassium  iodid?  It  is  never 
twice  the  same.  Fournier  is  surely  wrong  in  asserting  that 
less  than  oss  (2  gm.)  of  iodid  a  day  is  always  futile,  and 
equally  wrong  in  the  statement  that  "  what  a  dose  of  ten 
grams  (a  day)  will  not  achieve  no  higher  dose  will  achieve." 
Five  grains  three  times  a  day  may  perfectly  well  cure  a  lesion, 
and  it  is  the  proper  dose  to  begin  with,  for  one  should  always 
be  on  the  lookout  for  idiosyncrasy.  But  if  the  patient  can  take 
five  grains,  he  can  take  ten,  and  usually  twenty.  Accordingly, 
ten  to  twenty  grains  three  times  a  day  is  the  average  dose 
required. 

But  to  conquer  the  lesion  it  may  be  necessary  to  go  higher, 
and  if  the  lesion  is  in  the  nervous  system,  to  go  very  rapidly 
higher.      Where   shall   we   stop?   at   a   theoretic   ten   grams? 

1  So  thick  that  an  especially  large  needle  (sixteen  wire  gauge)  is  required 
and  a  syringe  the  piston  of  which  may  be  forced  down  by  screw-pressure — 
otherwise  one's  fingers  are  quite  bruised  by  the  pressure  required. 


METHOD    OF    ADMINISTRATION    AND    DOSAGE  201 

No,  nor  at  twenty.  Under  urgent  conditions  the  dose  must  be 
rapidly  increased  even  in  the  face  of  severe  poisoning.  Case 
VI  had  to  be  almost  killed  to  control  the  progress  of  her  dis- 
ease, and  I  have  recently  seen  a  tertiary  ulceration  of  the  lip, 
which  for  years  had  resisted  every  kind  of  mercurial  and  iodic 
medication,  cured  in  a  few  weeks  (by  Dr.  Chetwood)  by  the 
administration  of  a  dose  of  iodid  (oSS  a  day),  which  gave 
him  a  most  intense  hay  fever  and  closed  both  his  eyes  from 
facial  edema. 

Herein  lies  the  great  difference  between  the  use  of  iodid 
and  that  of  mercury.  //  mercury  poisons,  it  must  he  stopped 
at  once.  But  if  iodid  poisons,. it  may  still  he  pushed — in  some 
cases  it  must  he  pushed — for  iodism  is  but  a  slight  and  tem- 
porary inconvenience  compared  with  the  destructive  syphilitic 
lesions  against  which  iodids  are  employed.  Generally  speak- 
ing, therefore,  the  limit  to  the  dose  of  iodids  is  marked  hy  an 
improvement  in  the  lesion ;  they  must  he  pushed  until  the  lesion 
hegins  to  yield. 

Duration  of  Treatment. — For  stubborn  lesions,  however, 
this  doctrine  may  be  followed  too  literally.  Lesions  of  the 
nervous  system,  because  of  their  peculiar  stubbornness,  are 
likely  to  be  overtreated  unless  a  time  limit  is  set  to  the  course. 
This  subject  is  amply  discussed  elsewhere  (pages  141,  148). 
Suffice  it  to  say  that  a  severe  course  of  iodid  should  not  he 
continued  more  than  three  or  four  weeks.  Whether  the  lesion 
has  yielded  or  not  an  intermission  of  at  least  two  or  three 
weeks  for  purely  hygienic  treatment  should  then  follow,  after 
which  another  short,  sharp  course  of  iodid  may  be  begun. 

How  to  Increase  the  Dose. — One  usually  begins  with  five 
minims  of  the  "  saturated  "  solution  three  times  a  day.  This  is 
increased  one  or  two  minims  a  day  ^  until  fifteen  minims  is 
reached.     Thereafter  the  increase  may  be  more  rapid,  from 

1  If  one  minim,  v[\yi,  t.i.d.  the  second  day;  n^^vii  t.i.d.  the  third  day,  etc. 


202  THE    lODIDS— MIXED    TREATMENT 

three  to  five  minims  a  day;  and  after  the  doses  reach  twenty- 
five  minims  each,  from  five  or  ten  minims  a  day.  By  this 
course  it  takes  from  three  to  five  days  to  reach  a  ten-minim 
dose,  and  from  six  to  twelve  days  to  reach  a  twenty-minim 
dose. 

But  if  there  is  need  for  haste  such  slow  and  cautious  meas- 
ures must  be  discarded.  Suppose  you  are  called  to  treat  a  case 
of  syphilitic  hemiplegia  that  has  just  occurred.  It  may  be 
that  low  doses  would  cure,  but  you  have  no  right  to  take  the 
chance.  You  must  begin  with  lo-minim  doses  at  least  four 
times  a  day,  and  increase  lo  or  15  minims  a  day  until  40- 
or  50-minim  doses  are  reached.  Here  you  may  pause  for  a 
few  days,  hoping  the  symptoms  will  improve.  If  they  do  not, 
push  on,  increasing  by  lo-minim  bounds  until  either  the  lesion 
yields,  or  the  patient  is  utterly  iodized,  or  the  time  limit  of 
four  weeks  is  up.  Then,  after  an  interval,  a  secondary  course 
is  begun,  but  it  need  rarely  be  made  as  severe  as  the  first. 

MIXED   TREATMENT 

Thus  far  I  have  spoken  of  iodid  as  though  used  alone, 
and  as  a  matter  of  fact  it  is  often  so  employed.  But  it  is  my 
practice  never  to  itse  iodid  without  mercury.  My  reason  for 
this  is  that,  though  the  iodid  may  he  somezvhat  eificient  alone, 
its  efficiency  is  greatly  enhanced  by  the  use  of  mercury.  This 
fact  I  have  often  seen  exemplified,  but  never  more  clearly  than 
in  the  following  instance : 

Case  XXVI. — A  3'oung  man  came  to  me  in  the  summer  of 
1906  with  the  following  history :  In  1900  he  was  infected  with 
syphilis,  but  the  chancre  was  insignificant  and  the  subsequent 
lesions  consisted  of  only  an  occasional  sore  throat  and  mouth. 
After  a  year  or  so  these  disappeared,  untreated,  undiagnosed 
even.  In  1903  he  married,  and  promptly  impregnated  his  wife 
(mother  and  child  uninfected).     A  few  months  after  his  mar- 


METHOD    OF   ADMINISTRATION    AND    DOSAGE  203 

riage  he  consulted  a  physician  in  reference  to  a  persistent,  slug- 
gish sore  which  had  appeared  above  his  left  elbow  three  or  four 
months  before  and  was  slowly  spreading.  To  the  patient's  hor- 
ror the  physician  diagnosed  syphilis  and  prescribed  iodid  of 
potassium.  Up  to  this  time  he  had  taken  no  medicine  whatever ; 
since  then  he  has  taken  iodid  continually,  but  never  at  any  time 
a  grain  of  mercury. 

Before  beginning  the  iodid  he  was  some  ten  pounds  oflf 
weight ;  after  beginning  it  his  lesion  rapidly  improved  up  to  a  cer- 
tain point,  then  began  to  grow  larger.  To  combat  this  the  dose 
of  iodid  was  increased  to  the  limit  of  toleration  (about  ten 
grams  a  day)  and  the  lesion  again  checked,  but  not  cured. 
But  continued  taking  of  iodid  in  maximum  doses  soon  began  to 
tell  on  his  digestion ;  he  lost  more  weight,  and  another  sore  broke 
out  on  his  right  knee  (in  1905). 

Disgusted,  he  changed  his  physician ;  but  his  new  adviser 
improved  his  regime  only  by  the  substitution  of  interrupted 
courses  of  iodid  for  the  continuous  treatment  he  had  been  receiv- 
ing. Under  this  system  he  was  now  better,  now  worse ;  but  on 
the  whole  gradually  failing  until  he  consulted  me. 

At  that  time  he  was  thirty-four  pounds  off  weight,  so  feeble 
he  could  not  longer  follow  his  occupation  as  a  bookkeeper,  and 
his  digestion  so  completely  gone  he  could  not  digest  iodid  or 
much  of  anything  else.  Covering  his  right  knee  was  a  large, 
active,  syphilitic  ulceration  some  four  inches  in  diameter,  on  his 
left  elbow  a  smaller  similar  ulcer,  and  above  this  several  scars 
and  partially  healed  ulcerations. 

He  was  put  upon  a  diet,  instructed  in  hygiene,  and  given  an 
injection  of  gray  oil.  This  caused  him  so  much  suffering,  how- 
ever, that  it  seemed  wiser  to  continue  treatment  by  inunction 
(internal  treatment  being  out  of  the  question).  This  he  contin- 
ued (one  week  in  three)  for  six  months,  taking  no  iodid  what- 
ever. 

At  first  he  improved  rapidly,  gaining  ten  pounds  in  six  weeks 
and  resuming  his  work.  The  lesions  on  the  elbow  all  healed, 
and  after  three  months  the  ulcer  on  the  knee  was  reduced  to 
one  quarter  its  size  when  I  first  saw  it.  But  there  his  improve- 
ment stopped  (he  lived  out  of  town  and  I  saw  him  very  rarely), 
and  in  January  he  returned  with  the  leg  ulcer  showing  marked 


204  THE    lODIDS— MIXED    TREATMENT 

activity.  But  in  the  six  months  his  digestion  had  greatly  im- 
proved, lodid  was  therefore  resumed  and  run  up  to  one  gram 
t.i.d.  Under  this  the  ulcer  melted  away,  and  was  entirely  healed 
in  three  weeks. 

Here  were  lesions,  uncontrolled  by  three  years  of  iodid, 
improved  by  six  months  of  mercury  and  hygiene,  and  cured  by 
three  weeks  of  iodid  after  the  mercury.  The  moral  is  four- 
fold :  viz.  ( I )  W' ithout  any  treatment  the  disease  was  appar- 
ently cured  for  three  years  (and  a  healthy  child  begotten)  ; 
(2)  the  iodid  of  itself  had  some  effect  in  controlling  symp- 
toms; but  (3)  this  effect  was  greatly  enhanced  bv  the  admin- 
istration of  mercury,  though  (4)  the  mercury  alone  could  not 
effect  a  cure. 

This  treatment  of  syphilis  by  mercury  and  iodid  together 
is  called  .mixed  treatment.  The  two  are  ordinarily  given 
together  in  the  following  formula : 

^  Hydrarg.  chlorid.  corrosiv.,  gr.  j-ij  (0.6-1.2  gm.)  ; 

Potass,   iodid ^ij-gj    (8-30  gm.)  ; 

Syr.  sarsaparillse  comp.  .  .ad  oiv  (ad  130  c.c). 
M. 
S.     Teaspoonful  two  hours  after  meals. 

The  dose  may  be  and  usually  is  given  immediately  after 
eating,  but  it  is  better  digested  if  given  two  hours  later. 

In  the  above  formula  the  mercury  hiniodid  may  be  substi- 
tuted for  the  bichlorid,  in  half  the  dose.  Sodium  iodid  in  twice 
the  dose  may  replace  the  potassium  salt. 

If  the  patient  refuses  to  take  a  fluid  medicine  he  may  take 
his  iodid  as  a  tablet  half  an  hour  before  meals  and  the  mercury 
pill  or  tablet  after  meals.  The  mixed  treatment  pills  or  tablet 
put  up  by  various  drug  houses  have  not  given  me  much  satis- 
faction. 

But  w^hen  the  gravity  of  the  lesion  demands  hasty  or  ener- 


THE    TEST    COURSE  205 

getic  treatment,  or  when,  as  in  the  case  just  recited,  the  condi- 
tion of  the  patient's  digestion  prohibits  internal  treatment,  the 
mercury  must  be  given  by  injection,  fumigation,  or  inunction, 
the  iodid  by  saturated  sokition  or  injection  (iodipin,  Hpiodol). 


THE    TEST    COURSE 

We  shall  often  have  occasion  to  speak  of  a  "  test  course," 
administered  more  or  less  tentatively  to  prove  whether  a  lesion 
is  or  is  not  syphilitic.  It  were  ideal  to  have  a  definite  course 
upon  which  one  could  invariably  depend  for  a  verdict;  but  no 
two  lesions  yield  to  precisely  the  same  treatment,  and,  conse- 
quently, it  is  impracticable  if  not  impossible  to  apply  the  same 
test  to  every  case. 

The  general  rule  for  a  test  course  is  this :  Give  the  treat- 
ment as  though  the  lesion  were  known  to  be  syphilitic  and  you 
were  trying  to  cure  it. 

Thus  for  a  suspected  secondary  lesion  give  mercury;  for  a 
dubious  or  tertiary  lesion,  mixed  treatment. 

In  any  case  the  treatment  should  begin  mildly;  but  in  case 
it  does  no  good  should  be  rapidly  pushed  to  the  point  of 
salivation  or  iodism,  or  both,  in  order  to  reach  a  diagnosis  as 
soon  as  possible. 

It  is,  therefore,  usually  preferable  to  employ  one  of  the 
more  vigorous  methods  of  mercurial  treatment;  i.  e.,  injection, 
fumigation,  or  inunction,  and  to  give  the  iodid  in  drop  doses 
by  the  increasing  scale  (page  201).  Such  a  course,  lasting 
three  weeks,  should  be  ample  for  diagnosis. 


CHAPTER    XV 

CHANCROID 

Custom  in  America  has  adopted  the  name  "  chancroid  " 
(originated  by  Clerc)  for  that  form  of  contagious  venereal 
ulcer  which  is  not  accompanied  by  constitutional  syphilitic  in- 
fection. Chancroid  (or  soft  chancre)  and  hard  chancre  are 
no  more  akin  than  measles  and  leprosy;  and  it  is  unfortunate 
that  the  ancient  confusion  of  the  local  and  the  general  infec- 
tion has  left  us  this  legacy  of  misleading  terms ;  but  it  is  now 
too  late  to  change  them. 

Definition. — Chancroid  is  a  specific,  local,  contagious,  auto- 
infectious  venereal  ulcer. 


Fig.  4. — Streptobacillus  of  Ducrey  (highly  magnified).     (J.  L.  Da\as.) 

It  IS  Specific  in  that  it  is  caused  by  a  specific  microorgan- 
ism, the  streptobacillus  of  Ducrey  ^  (Fig.  4). 

1  Riforma  medica,  1889,  vol.  v,  p.  98. 
206 


CHANCROID  207 

This  bacillus  is  dumb-bell  shaped,  thick  and  rounded  or 
square  at  the  ends,  constricted  in  the  middle.  It  varies  in 
length  from  1.5  to  2  jti.    It  groups  in  parallel  chains,  and  occurs 


Fig.  5. — Streptobacillus,  Showing  Chain  Formation.     (J.  L.  Davis.) 

both  inside  and  outside  the  cells  (Fig.  5).  It  stains  readily 
with  the  ordinary  dyes  (methyl-blue,  or  violet,  or  fuchsin), 
and  is  decolorized  by  the  Gram  stain. 

For  many  years  after  its  discovery  in  1889,  in  spite  of  the 
confirmatory  observations  of  Unna,  Kretling.  Dubreuilh,  and 
Lasnet,  etc.,  and  in  face  of  the  manifestly  specific  character  of 
chancroid,  the  pathogenic  action  of  the  streptobacillus  was 
doubted  until  proven  by  the  culture  and  inoculation  experi- 
ments of  Istamanoff  and  x\skpianz,^  Lincoln  Davis,-  Lancret,^ 
and  Tomasczewski.^  But  chancroid  is  peculiarly  liable  to 
mixed  infection.  A  smear  taken  from  the  surface  of  the  ulcer 
usually  shows  numerous  pyogenic  and  other  bacteria,  and  few 
if  any  of  the  pathogenic  bacilli.  Hence  such  a  smear  cannot 
be  depended  upon  for  diagnosis. 

^  Jahresbericht  d.  Path. — Microorg.,  1898,  vol.  xiv. 

2/.  of  Med.  Research,  1904,  vol.  ix,  p.  401. 

^  Bull,  med.,  1898,  vol.  xii,  p.  105 1. 

* Zeitschr.  /.  Hygiene  u.  Infect.,  1903,  vol.  xiii,  p.  327. 


2o8  CHANXROID 

Chancroid  is  a  local  lesion,  causing  no  systemic  infection 
or  reaction.  It  is,  therefore,  indefinitely  aiitoinociilahle.  In- 
deed, the  marked  tendency  to  autoinoculation  is  one  of  the 
most  striking  clinical  characteristics  of  the  ulcer.  That  it  con- 
fers no  immunity  whatever  was  amply  proven  by  the  disciples 
of  syphilization.  Lindemann,  for  example,  inoculated  him- 
self 2,^00  times  with  chancroidal  pus  in  the  vain  hope  of  im- 
munizing himself  against  syphilis.  But  a  local  and  temporary 
immunity  does  exist;  for  after  many  inoculations  a  given  re- 
gion becomes  immune,  though  the  virus  will  still  take  on  other 
parts  of  the  body,  and  after  several  months'  respite  the  first 
region  loses  its  immunity.  Clinically,  however,  such  immunity 
has  no  significance. 

Finally,  chancroid  is  a  contagious  venereal  ulcer.  Of  the 
three  distinct  venereal  diseases,  gonorrhea,  chancroid,  and 
syphilis,  gonorrhea  is,  strictly  speaking,  the  most  venereal, 
being  scarcely  ever  acquired  except  in  sexual  intercourse. 
Chancroid,  though  probably  more  virulent,  is  less  venereal, 
since  it  recognizes  many  methods  of  infection  other  than  sexual 
congress;  while  syphilis  is  the  least  virulent  (the  least  easily 
acquired)  and  the  least  venereal. 

Chancroid  is  an  affection  perpetuated  only  by  contagion; 
but  sexual  intercourse  is  not  essential.  Wherever  upon  the 
human  body  a  chancroid  is  found,  there,  it  may  be  positively 
affirmed,  pus  from  some  other  chancroid  has  been  deposited 
under  conditions  favorable  for  its  absorption.  No  amount  of 
sexual  excess,  no  degree  of  uncleanliness,  no  irritation,  trau- 
matic or  chemical,  however  prolonged,  no  simple  or  infected 
ulceration,  nothing,  in  short,  can  produce  chancroid  except 
chancroid. 

Frequency. — In  the  clinic  chancroids  outnumber  true 
chancres  three  or  four  to  one.  In  private  practice  the  pre- 
ponderance is  reversed,  and  we  see  five,  or  even  ten.  chancres 
to  one  chancroid.      The  reason   for  this  is  twofold.      In  the 


CHANCROID  209 

first  place,  chancroid  can  never  make  headway  among  cleanly 
persons,  for  it  is  so  foul  and  disgusting  that  no  decent  citizen 
infected  with  it  would  attempt  sexual  intercourse  until  it  is 
cured,  and  half  a  cure — such  as  so  commonly  conceals  the 
infectiousness  of  syphilis  and  gonorrhea — is  here  impossible. 
In  the  second  place,  in  most  instances,  a  little  soap  and  water 
at  the  time  of  exposure  is  an  absolute  safeguard  against  it ;  so 
that  it  flourishes  only  where  soap  and  water  are  not  esteemed. 

Methods  of  Contagion. — Xot  once  in  a  thousand  cases  does 
one  see  a  chancroid  except  about  the  genitals.  This  is  as  much 
as  to  say  that  it  is  practically  always  acquired  by  sexual  con- 
tact. Although  many  cases  of  mediate  contagion  have  been 
reported  (the  virus  being  usually  conveyed  by  the  hand),  such 
cases  are  proportionately  extremely  rare.  Indeed,  chancroid 
will  not  "  take  "  upon  the  integument  unless  it  is  abraded. 
Cullerier's  experiments  show  that  this  must  oftentimes  be  true 
of  the  vagina  as  well.  In  two  cases  he  deposited  pus  from  a 
chancroidal  bubo  in  a  clean  vagina,  and  let  it  remain  there 
between  half  an  hour  and  an  hour.  Then  some  of  the  vaginal 
secretion  was  collected  and  inoculated  upon  the  thigh,  after 
which  the  vagina  was  thoroughly  cleansed.  In  both  instances 
typical  chancroids  developed  on  the  thigh  while  the  vagina 
remained  clean. 

Hence,  be  it  noted,  a  woman  may  convey  chancroid  from 
one  man  to  another  without  herself  becoming  infected. 

Yet  autoinoculation  of  chancroid  upon  the  healthy  skin  or 
mucous  membrane  lying  in  contact  with  it  is  extremely  com- 
mon. But  it  takes  many  hours  of  intimate  contact  to  effect 
the  inoculation. 

Situation  and  Number. — Chancroids  upon  the  male  geni- 
tals are  most  common  in  the  coronary  sulcus,  especially  in  the 
little  pocket  on  each  side  of  the  frenum.  Persons  with  long 
foreskins  may  be  inoculated  anywhere  within  the  preputial 
cavity,  though  urethral  chancroid  is  extremely  rare. 


2IO 


CHANCROID 


In  women  the  sores  usually  occur  about  the  introitus, 
rarely  higher  up. 

From  these  regions  the  ulcers  may  spread  by  contact  or 
by  direct  extension  over  external  genitals,  anus,  thighs,  abdo- 
men, and  even  farther  afield. 

Chancroid  commonly  begins  as  a  single  ulcer;  but  no 
sooner  has  this  appeared  than  secondary  ulcerations  begin,  so 


Fig.  6.— Chancroids  of  Prepuce,  Preputial  Frenum,  and  Glans  Penis,  in 
Various  Stages  of  Development.     (Kaposi.) 

that  by  the  time  the  physician  is  consulted  several  sores  are 
usually  present. 


SYMPTOMS   AND    COURSE 

Incubation. — While  Bumstead  affirmed  that  chancroid  has 
no  period  of   inoculation   in  the   sense  that  the  pathological 


SYMPTOMS   AND    COURSE 


211 


process  begins  from  the  moment  of  infection,  it  is,  neverthe- 
less, true  that,  cHnically,  the  disease  has  an  incubation  period 
varying  from  one  to  ten  days,  usually  three  to  five.  When  the 
incubation  is  protracted,  this  is  probably  due  to  the  fact  that 


Fig.  7. — Chancroid  that  has  Destroyed  the  Frenum.     (Kaposi.) 


the  virus  is  retained  some  days  within  the  prepuce  (or  vagina) 
before  inoculation  occurs. 

Onset. — The  symptoms  of  chancroid  are  best  observed  by 
studying  the  course  of  the  artificial  ulcer  produced  by  inocula- 
tion. Within  twenty-four  hours  after  such  an  inoculation  a 
reddish  blush  surrounds  the  puncture.  This  soon  changes  to  an 
inflamed  areola  which,  on  the  third  day  (rarely  sooner  or 
later),  becomes  a  pustule.  This  extends  quite  rapidly,  and 
"within  a  few  days  breaks  and  becomes  a  characteristic  chan- 
croidal ulcer  (Figs.  6,  7,  8,  and  13). 

16 


212 


CHANCROID 


The  Ulcer. — The  typical  chancroid  is  a  round  ulcer  with 
abrupt,  perpendicular  edge,  as  though  it  had  been  cut  by  a 
sharp  punch.  This  edge  may  be  undermined  or  everted.  The 
ulcer  is  usually  rather  deep.     Its  base  is  irregular,   grayish 

yellow,  and  covered  by 
a  pultaceous  false  mem- 
brane. It  is  surrounded 
by  a  non-indurated,  in- 
flammatory areola.  The 
secretion  is  abundant  and 
purulent.  It  bleeds  read- 
ily. Though  usually 
painless,  when  very  act- 
ive or  phagedenic  it  may 
be  intensely  painful. 

Course. — If  untreat- 
ed and  uncomplicated 
the  ulcer  increases  in  size 
for  a  week  or  two. 
Then,  having  attained  a 
diameter  of  about  icm., 
it  remains  stationary  for 
about  two  weeks,  and 
then  gradually  heals  by 
cicatrization  from  the 
edges  toward  the  cen- 
ter. So  rarely,  however, 
is  the  ulcer  both  uncom- 
plicated and  untreated  that  the  stage  of  spontaneous  healing  is 
not  seen  in  the  clinic. 

Complications. — The  common  complications  of  chancroid 
are  mixed  infection  with  syphilis  (mixed  sore),  mixed 
infection  with  pyogenic  microbes  (inflamed  chancroid),  de- 
struction of  the  frenum,  phimosis,  gangrene  and  phagedena. 


Fig.  8. — Chancroids  of  Vulva.     (Kaposi.) 


SYMPTOMS   AND    COURSE  213 

balano-posthitis  and  venereal  warts,  lymphangitis,  adenitis 
(bubo). 

The  Mixed  Sore. — So  long  as  your  patient  has  chancroid 
you  may  never  be  sure  that  he  has  not  chancre.  This  rule  is 
without  exception.  Its  details  and  explanation,  the  necessary 
insistence  upon  the  fact  that  a  chancroid  may  readily  conceal 
a  chancre  from  the  most  experienced  eye,  as  well  as  that  other 
often-forgotten  fact  that,  when  the  chancroid  refuses  to  heal, 
it  may  be  because  of  complicating  gumma — these  matters  are 
discussed  elsewhere  (page  246). 

The  Inflamed  Chancroid. — While  every  chancroid  is 
more  or  less  irritated  by  its  own  secretions  and  contaminated 
by  ordinary  pyogenic  microbes,  the  resulting  inflammation  is 
often  insignificant  unless  due  to  friction,  e.  g.,  when  the  sore 
is  on  the  edge  of  a  long  prepuce  and  subject  to  friction  by  the 
patient's  clothes,  or  unless  there  is  phimosis. 

The  chancroid  at  the  preputial  orifice  is  usually  an  inter- 
minable while  getting  well.  The  friction  of  shirt  and  drawers, 
or  even  the  rubbing  of  the  softest  dressing,  so  irritates  the 
sore  that,  though  it  may  lose  all  its  chancroidal  characteristics 
and  become  a  simple,  sluggish  abrasion,  it  lingers  on  week 
after  week,  taxing  to  the  utmost  the  victim's  patience  and  the 
physician's  skill. 

Chancroid  underneath  a  long  prepuce,  however  loose,  usu- 
ally excites  so  acute  a  cellulitis  in  the  connective  tissue  of  the 
foreskin  as  to  cause  inflammatory  phimosis.  This  retains  the 
secretions  of  the  chancroid  which,  bathed  in  this  irritating  pus 
and  protected  from  effective  treatment,  promptly  invades  both 
glans  and  prepuce,  and  instead  of  healing  tends  rather  to  eat 
its  way  through  the  glans  penis  into  the  urethra  or  through 
the  foreskin,  at  the  same  time  setting  up  an  intense  inflamma- 
tion, which  may  terminate  in  abscess,  erysipelas,  or  gangrene. 
If  the  prepuce  is  retracted  in  a  desperate  effort  to  get  at  the 
suppurating  cavity,  paraphimosis  complicates  matters. 


214  CHANCROID 

Destruction  of  the  Frenum. — One  of  the  commonest 
complications  of  chancroid  is  destruction  of  the  preputial 
frenum.  Indeed,  the  scar  of  this  lesion  may  in  after  years 
prove  most  valuable  in  distinooiishing  chancroid  from  true 
chancre. 

The  frenum  is  destroyed  in  the  following  manner :  a  chan- 
croid appears  in  the  sulcus  at  one  or  both  sides  of  the  frenum ; 
as  it  enlarges  it  eats  a  hole  in  the  frenum,  leaving  a  narrow 
string,  which  soon  gives  way  as  well. 

The  more  widespread  destruction  of  tissue  that  results 
from  inflammation  or  phagedena  requires  no  special  mention. 

Gangrene  and  Phagedena. — The  terrible  phagedena 
which,  until  the  era  of  antisepsis,  was  an  imminent  possibility 
for  every  case  of  chancroids,  has  almost  passed  to  oblivion 
with  hospital  gangrene  and  such  ancient  horrors.  One  can 
no  longer  imagine  such  a  case  as  Ricord  treated  for  several 
years,  and  which,  commencing  as  a  chancroidal  bubo  fourteen 
years  before,  was  still  an  open  ulcer  at  the  knee. 

On  the  other  hand,  gangrene  foudroyante  is  still  occasion- 
ally encountered  as  the  complication  of  stricture,  or  of  chan- 
croid. Thus  Martin  ^  relates  and  depicts  the  case  of  a  man 
who  lost  two  thirds  of  his  penis  by  gangrene  in  thirty-six 
hours.     Happily,  such  cases  are  now  extremely  rare. 

Lymphangitis; — Acute  inflammation  of  the  lymphatics 
running  along  the  dorsum  and  sides  of  the  penis  toward  the 
inguinal  glands  is  a  rare  complication.  Suppuration  therein 
is  much  rarer. 

Inguinal  Adenitis. — Chancroid  of  the  genitals  causes 
inguinal  adenitis  or  bubo.  This  complication  occurs  about 
once  in  every  three  cases.  The  bubo  when  bilateral  is  usually 
more  severe  on  the  side  upon  which  the  sore  lies ;  but,  on  ac- 
count of  an   abnormal   lymphatic   supply,   the  glands   in  the 


1  Morrow's  "System,"  p.  875. 


SYMPTOMS    AND    COURSE  215 

opposite  groin  may  be  the  more  inflamed.  This  is  the  so-called 
"  crossed  bubo.'' 

The  chancroidal  bubo  follows  one  of  three  clinical  types. 

It  may  be  a  simple  inflammatory  adenitis,  the  glands  be- 
coming large  and  quite  tender,  so  remaining  for  a  week  or 
more,  and  then  slowly  resolving. 

It  may  go  on  to  periadenitis.  The  glands  become  matted 
together  in  irregular,  tender  masses  adherent  to  the  skin  and 
to  the  subjacent  tissues.  When  the  inflammation  reaches  this 
stage  it  often  terminates  by  suppuration ;  and  when  the  abscess 
is  incised  or  breaks,  it  heals  in  a  way  no  different  from  sup- 
purations elsewhere. 

Finally,  the  inflammation  may  go  through  the  same  stages 
of  adenitis,  periadenitis,  and  suppuration ;  but  when  opened  it 
forms  an  ulcer  which  soon  assumes  the  aspect  of  a  chancroid, 
the  pus  from  which  is  autoinoculable.  This  is  the  so-called 
virulent  bubo. 

The  obvious  explanation  of  these  variations  in  virulence 
is  that  the  milder  forms  of  bubo  are  due  to  the  absorption  of 
pyogenic  microbes,  and  that  virulent  bubo  is  due  to  the  absorp- 
tion of  the  specific  bacillus.  But  it  has  frequently  been  ob- 
served that,  whereas  the  pus  obtained  from  buboes  at  the 
moment  of  incision  is  very  rarely  chancroidal,  it  becomes  so 
a  few  days  afterwards.-^  Hence,  it  has  been  supposed  that 
such  buboes  are  infected  secondarily  with  the  chancroidal 
bacillus. 

Recent  bacteriological  investigations  have  upset  this  the- 
ory.     Tomasczewski  -    found    that,    although    the   microscope 

'Thus  Dubreuilh  (/.  de  med.  de  Bordeaux,  1893,  vol.  xxiii,  p.  573)  has 
reported  an  epidemic  of  chancroids  producing  136  buboes.  Of  these,  27  did 
not  suppurate;  43  were  incised;  the  pus  was  sterile  to  culture  and  they  healed 
rapidly;  51  became  virulent,  though  sterile  when  incised;  only  3  were  virulent 
at  the  time  of  incision;  and  12,  which  were  open  on  admission  to  the  hospital, 
were  all  virulent. 

2  Arch.  f.  Derm.  u.  Syph.,  1904,  vol.  Ixxi,  p.  i 


2l6  CHANCROID 

showed  nothing  in  the  pus  from  a  freshly  incised  chancroidal 
bubo,  culture  on  blood  agar  revealed  streptobacilli  of  very 
slight  virulence,  while  in  older  lesions  the  same  bacteria  were 
found  with  renewed  virulence. 

Now  it  has  long  been  known  that  chancroidal  pus,  although 
it  would  remain  virulent  for  many  weeks  if  kept  in  a  sealed 
tube,  promptly  lost  its  virulence  when  heated  to  a  temperature 
of  105°  F.  It  is,  therefore,  to  be  inferred  that  both  "  simple  " 
and  "  virulent  "  buboes  are  due  to  infection  by  the  strepto- 
bacillus,  but  that  the  heat  engendered  in  the  inflamed  gland 
is  sufficient  to  reduce  its  virulence  sometimes  to  the  point  of 
rendering  it  temporarily  inocuous ;  so  that  it  only  requires  a 
few  days  of  cooling  off,  as  it  were,  in  the  open  ulceration  to 
regain  its  primitive  vigor. 

DIAGNOSIS 

The  diagnosis  of  chancroid  may  be  made  by  the  micro- 
scope (which  gives  no  negative  assurance),  by  culture  on  blood 
agar,  by  the  ancient  and  very  trustworthy  method  of  auto- 
inoculation,  or  by  confrontation  (examination  of  the  person 
from  whom  the  sore  was  contracted). 

To  perform  autoinoculation,  cleanse  a  spot  on  the  outer 
side  of  the  patient's  thigh  with  alcohol;  then  with  a  clean 
bistoury  or  pin  wipe  a  little  pus  from  the  suspected  sore ;  twirl 
the  point  of  the  instrument  into  the  skin  at  the  point  to  be 
inoculated  just  deep  enough  to  draw  the  most  minute  drop 
of  blood,  smear  the  spot  well  with  the  virus,  and  clap  on  a 
vaccination  shield.  A  "  take  "  is  announced  by  the  appear- 
ance of  a  typical  chancroid  on  the  third  day.  This  should 
promptly  be  destroyed  by  cauterization  (see  below). 

The  mere  appearance  of  a  pustule  or  an  ulcer  after  inocu- 
lation proves  nothing.  It  must  be  chancroidal  in  type  to  be 
considered  trustworthy  evidence.     If,  after  inoculation,  there 


TREATMENT  217 

is  still  some  doubt  of  the  nature  of  the  "  take,"  its  secre- 
tions may  be  examined  for  the  Ducrey  bacillus  with  better 
prospect  of  success  than  in  the  original  sore,  or  the  diagno- 
sis may  be  confirmed  by  heteroinoculation  (inoculation  of 
another  person).  Gangrenous  chancroid  is  said  not  to  be 
inoculable. 

Generally  speaking,  however,  no  test  is  required  to  estab- 
lish the  diagnosis  of  chancroid.  The  multiple,  virulent 
sloughing  ulcers,  spreading  by  contact  inoculation,  the  char- 
acteristic bubo,  and  the  history  of  very  recent  exposure  form 
a  typical  clinical  picture.  Inflamed  herpes  or  simple  ulcer 
may,  however,  very  closely  simulate  beginning  chancroid. 
Moreover,  the  chancroid  may  originate  in  the  orifice  of  a 
sebaceous  gland  of  the  scrotum  or  penis  (follicular  chancroid), 
and  so  be  mistaken  at  first  for  a  small  boil  or  an  acne  pustule. 
Bullous  and  ecthymatous  forms  of  chancroid  are  extremely 
rare. 

But  the  really  important  point  in  the  diagnosis  of  chan- 
croid is  its  differentiation  from  true  syphilitic  chancre.  The 
details  of  this  differentiation  are  considered  elsewhere  (page 
246)  ;  but  it  is  not  amiss  to  repeat  once  again  that  no  matter 
how  sure  you  may  be  that  a  given  sore  is  a  chancroid,  you 
cannot  thereby  make  a  negative  diagnosis  of  syphilis;  for  the 
same  coitus  that  transmitted  the  chancroid  may  have  trans- 
mitted syphilis,  the  chancre  of  which  might  not  develop  until 
after  the  chancroid  was  cured,  or  might  develop  on  the  chan- 
croid, and  be  so  insignificant  as  to  escape  the  most  careful 
scrutiny. 

TREATMENT 

Abortive  Treatment. — Any  chancroid  not  more  than  three 
days  old  may  be  cured  by  adequate  cauterization.  Chancroids 
from  three  to  seven  days  old  may  often  be  thus  aborted;  but 
if  the  sore  is  more  than  a  week  old  success  is  so  rare  that 


2i8  CHANCROID 

cauterization  should  not  be  employed;  for,  if  it  fails,  it  leaves 
the  sore  larger  than  ever. 

It  is  an  absolute  condition  to  success  that  every  sore  be  cau- 
terized; not  only  those  sores  that  have  already  developed,  but 
also  those  that  are  only  just  beginning  as  minute  pustules, 
or  ulcers,  but  which,  however  small,  can  recontaminate  their 
larger  brethren,  however  well  these  be  cauterized.  Hence, 
nothing  more  futile  could  be  imagined  than  cauterization  of 
sores  on  the  outside  of  the  frenum  so  long  as  an  inflammatory 
phimosis  prevents  access  to  those  within  the  preputial  cavity, 
or  cauterization  of  balanitic  chancroids  in  the  presence  of 
inaccessible  urethral  sores. 

The  simplest  method  of  cauterization  is  the  following: 

1.  Wash  the  ulcer  and  surrounding  region  with  peroxid 
of  hydrogen  and  water,  equal  parts ;  then  dry. 

2.  Anoint  the  immediate  neighborhood  of  the  ulcer  with 
vaselin  to  keep  it  from  contact  with  the  acids  (not  absolutely 
essential). 

3.  Cut  several  narrow  strips  of  blotting  paper.  With  one 
of  these  dry  the  surface  of  the  ulcer. 

4.  Dip  the  pointed  end  of  a  glass  rod  into  pure  carbolic 
acid  and  apply  it  over  the  ulcerated  surface.  If  there 
is  any  excess  of  acid  running  over  the  edge  of  the  sore, 
quickly  catch  this  with  one  of  the  strips  of  blotting  paper. 
If  there  are  several  sores,  carbolize  them  all  before  proceeding 
further. 

The  object  of  this  step  is  not  cauterisation,  hut  anesthesia. 
Carbolic  acid  will  not  destroy  the  bacteria  in  the  tissues,  but 
will,  after  the  first  sting,  anesthetize  the  sore.  If  the  patient 
is  extremely  sensitive  and  nervous,  a  ten  per  cent  cocain  solu- 
tion may  be  used  instead  of  the  carbolic  acid.  Its  action  is 
much  slower  and  no  more  effective. 

5.  After  the  whole  surface  of  the  ulcer  has  been  fully 
whitened  by  the  carbolic  acid,  dry  again  with  blotting  paper 


TREATMENT  219 

and  apply,  very  cautiously,  with  another  glass  rod  pure  nitric 
acid/  Apply  this  in  droplets  until  the  whole  surface  is  stained 
yellow  or  brown. 

6.  Wash  again  with  peroxid  and  water  and  cover  with 
calomel  or  nosophen. 

Iodoform  is  by  far  the  best  dressing  for  chancroid,  but  its 
odor  and  reputation  are  prohibitive. 

If  the  first  cauterization  fails,  it  is  futile  to  repeat  it. 

Palliative  Treatment. — Since  every  uncomplicated  chan- 
croid tends  to  get  well  spontaneously,  it  may  be  treated  ex- 
pectantly, if  cauterization  is  prohibited  by  the  age  of  the  lesion 
or  the  refusal  of  the  patient. 

The  lesion  must  be  kept  mechanically  clean  and  covered 
with  some  antiseptic.  To  do  this,  wash  twice  a  day  with 
peroxid  and  water  and  keep  it  dusted  with  calomel  -  (iodo- 
form is  still  the  best,  but  the  most  impossible  application,  and 
nosophen  is  the  only  one  of  its  many  "  substitutes  "  that  has 
given  me  any  satisfaction).  Never  put  grease  on  a  chancroid. 
An  occasional  application  of  silver-stick  or  of  pure  carbolic 
acid  stimulates  the  granulations. 

If  the  chancroid  lies  within  the  preputial  cavity,  cover  it 
solely  with  the  powder.  If  it  lies  outside,  protect  it  from 
friction  by  a  large  pad  of  cotton  held  in  place  by  a  bandage  or 
a  bag. 

Prevention  of  Bubo. — Warn  the  patient  to  avoid  all  vio- 
lent exercise,  and  to  walk  about  as  little  as  possible  in  the 
hope  of  preventing  suppurating  bubo.  Watch  the  groins  care- 
fully, and  with  the  first  sign  of  periadenitis  (matting  together 
of  the  glands)  clap  him  into  bed  with  a  hot-water  bag  on  his 
groin. 


1  The  actual  cautery  is  preferred  by  some,  but  is  too  terrifying  a  sight  for 
most  patients. 

2  Many  efforts  have  been  made  to  diminish  the  virulence  of  the  bacteria  by 
external  applications  of  heat  but  without  any  great  success. 


220  CHANCROID 

Do  not,  under  any  circumstances,  paint  the  groin  with 
iodin.  It  does  no  good  and  irritates  the  skin;  so  that,  if  the 
bubo  does  eventually  suppurate  and  burst,  the  surrounding 
skin  is  ready  for  inoculation. 

Treatment  of  Complications.— Cellulitis  and  suppuration 
call  for  wet  dressings,  rest  in  bed,  elevation  of  the  penis,  and 
incision,  secundum  artein. 

Phimosis,  whether  congenital  or  inflammatory,  is  the  most 
annoying  complication  of  chancroid.  A  chancroid  under  a 
tight  foreskin,  unless  it  can  be  aborted  by  early  cauterization, 
demands  prompt  liberating  incision. 

Incision  of  Foreskin. — This  little  operation  is  performed 
under  infiltration  anesthesia,  particular  care  being  taken  to 
anesthetize  the  mucous  membrane.  A  grooved  director  is  then 
inserted  under  the  foreskin  (not  in  the  urethra,  if  you  please), 
and  upon  this  the  skin  and  mucous  membrane  are  split  with 
scissors  ^  or  knife  from  the  free  margin  well  back  to  the 
corona. 

It  is  better  practice  to  make  two  such  incisions,  one  on 
each  side  of  the  penis,  as  recommended  by  Taylor,  rather  than 
to  make  the  single  dorsal  incision,  which  does  not  thoroughly 
expose  the  pockets  on  each  side  of  the  frenum. 

Do  not  suture,  but  protect  the  incision  by  i  :  5,000  bichlorid 
wet  dressings  in  the  hope  of  preventing  chancroidal  inoculation 
of  the  wound. 

After  the  chancroids  have  healed  a  secondary  circumcision 
is  usually  required. 

If  the  patient  refuses  operation,  the  best  that  can  be  done 
for  him  is  to  inject  the  preputial  cavity  with  ten  per  cent 
argyrol  solutions  frequently — or,  better  still,  refuse  to  treat 
him  at  all ;  for  it  is  quite  impossible  to  foretell  what  compli- 
cations may  ensue,  and  no  physician  can  afford,  even  occasion- 


Bandage  shears  are  the  best. 


TREATMENT  221 

ally,  to  be  responsible  for  a  pathological  amputation  of  the 
glans  penis. 

Above  all  things,  do  not  pull  back  a  tight  prepuce.  The 
paraphimosis  which  will  probably  result  is  not  easy  to  reduce, 
and  is  the  most  fertile  cause  of  gangrene. 

Phagedena  demands  general  anesthesia  and  extensive  cau- 
terization of  every  recess  with  the  actual  cautery,  followed  by 
wet  dressings  and  iodoform.  Do  not  fear  to  cauterize  too 
much. 

Delayed  healing  is  the  commonest  and  most  annoying  com- 
plication of  chancroid  outside  the  preputial  cavity.  To  encour- 
age healing,  protect  the  sore  with  a  voluminous  dressing  of 
cotton,  and  cauterize  it  once  a  week  with  nitrate  of  silver, 
applying  in  the  meanwhile  some  stimulating  lotion,  such  as 
red  or  black  wash,  or  boric-acid  ointment. 

Partial  erosion  of  the  freniim  forms  a  pocket  which  is  very 
hard  to  clean.  Tie  a  thread  tightly  around  the  remaining  band, 
and  it  will  cut  through  within  forty-eight  hours. 

Suppurating  bubo  should  be  drained  by  very  small  inci- 
sions, almost  punctures,  multiple  if  need  be,  followed  by  injec- 
tion of  a  ten  per  cent  iodoform-in-glycerin  mixture.  Then 
apply  wet  dressings  (or  iodoform)  topped  by  a  hot-water  bag. 
If  after  several  weeks  the  indurated  masses  of  periadenitis 
show  no  tendency  to  decline  they  must  be  excised.  Usually  the 
mass  softens  immediately  and  leaves  a  large  chancroidal  ulcer. 
The  treatment  of  this  is  detailed  above. 

Excision  of  the  Inguinal  Lymph  Nodes. — This, 
though  a  minor  surgical  operation,  is  a  long  and  tedious  one, 
and  usually  leaves  a  wound  that  takes  several  months  to  heal. 

The  one  important  precaution  in  operating  is  to  avoid  the 
femoral  vessels  around  which  (at  the  saphenous  opening)  the 
nodes  are  usually  clustered. 

Further  detail  need  not  be  attempted  here. 


CHAPTER    XVI 
THE  INITIAL  LESION 

The  initial  lesion  (primary  lesion)  of  syphilis  consists  of 
the  chancre  and  the  adjacent  adenitis.  It  must  not  be  forgot- 
ten that  the  inflamed  lymph  nodes  form  as  essential  and  char- 
acteristic a  part  of  the  initial  lesion  as  does  the  chancre  itself. 

THE   CHANCRE 

Synonyms. — Hard  chancre,  Hunterian  chancre,  indurated 
chancre,  syphilitic  chancre,  primary  sore. 

Description. — The  chancre  is  an  eroded  or  ulcerated,  pain- 
less neoplasm,  arising  at  the  site  of  syphilitic  inoculation. 

The  chancre  is  primarily  a  neoplasm.  By  bearing  this  in 
mind  we  distinguish  it  instinctively  from  chancroid,  which  is 
primarily  an  ulcer.     The  one  is  a  lump,  the  other  a  hole. 

This  neoplasm  is  commonly  called  the  induration.  This 
induration  may  be  very  extensive;  it  may  form  a  large  hard 
lump,  projecting  markedly  above  the  surrounding  tissues  and 
having  a  diameter  of  perhaps  an  inch.  But  usually  (in  eight 
cases  out  of  ten)  it  is  small — one  might  almost  say  minute — 
and  instead  of  projecting  above  the  integument  it  is  embedded 
in  it.  Thus,  it  may  be  felt  rather  than  seen,  and  in  appear- 
ance is  rather  insignificant  than  impressive. 

The  surface  of  this  insignificant  neoplasm  is  almost  always 
eroded  and  moist,  but  it  may  be  ulcerated,  or  it  may  be  covered 
by  an  unbroken  reddened  integument. 


THE   CHANCRE 


223 


Its  consistency  is  peculiarly  hard  and  elastic,  as  though  a 
piece  of  cardboard  were  embedded  in  the  integument.  To 
appreciate  this  one  must  pick  it  up  from  the  surrounding  tis- 
sues and  palpate  it  from  side  to  side. 

Morbid  Anatomy. — The  chancre  has  the  general  charac- 
teristics of  syphiloma.  So  brilliant  a  pathologist  as  Virchow 
said  "  chancre  is  but  a  gummatous  ulcer."  Accordingly,  we 
find  in  a  connective-tissue  framework  a  mass  of  plasma  cells, 
leukocytes,  deformed  epithelial  cells — all  the  elements  of  an 
acute  localized  exudative  inflammation.  The  vessels,  espe- 
cially the  arteries,  are  infiltrated,  irregularly  thickened,  and 
occluded.  The  surface  of  growth  is  more  or  less  necrotic, 
whence  the  erosion  or  ulceration.  Proper  staining  shows  an 
occasional  spirocheta  in  the  substance  of  the  chancre. 


Fig.  9. — Pathology  of  Eroded  Chancre  (diagrammatic),  a,  Desquamating 
epithelium  (erosion),  h,  c,  Infiltration  of  epidermis  and  derma  (induration). 
d.  Perivascular  exudate  at  a  distance  from  the  chancre,     e,  Normal  skin. 


This  inflammation  diminishes  insensibly  toward  the  bor- 
der of  the  induration  and  extends  into  the  surrounding  tissue 
far  beyond  the  apparent  limits  of  the  growth.  The  infiltra- 
tions in  the  vessel  walls,  in  particular,  extend  beyond  the  pal- 


224 


THE    INITIAL   LESION 


pable  seat  of  the  disease.  Yet  the  depth  of  the  chancre  is 
almost  nil.  It  occupies  chiefly  the  epidermal  layer  of  the 
skin,  encroaching  but  little  on  the  true  derma  and  the  subja- 
cent tissue  (Figs.  9,  10). 


Fig.  10. — Pathology  of  Ulcerated  Chancre  or  Ulcerated  Syphilitic 
Tubercle  (diagrammatic).  The  induration  {a,  b)  is  deep  set.  The  ulcer 
(a)  has  destroyed  the  skin  and  will  leave  a  scar.  The  infiltration  follows  the 
vessels  (c)  beyond  the  lesion. 


Multiple  Chancres.  —  The  most  striking  characteristic  of 
chancre  is  its  insignificance ;  next  in  order  of  importance  is  its 
uniqueness.  Yet  too  much  stress  may  be  laid  upon  this.  The 
chancre  is  usually  single,  to  be  sure,  yet  Papagaey/  who  col- 
lected 14,004  reported  cases,  found  that  in  from  twenty-five 
per  cent  to  thirty-three  per  cent  the  chancres  were  multiple. 
This  confirms  other  Continental  statistics;  yet  multiple  chan- 
cres are  certainly  much  fewer  in  my  practice.  My  records 
show  only  56  among  549  cases  examined,  i.  e.,  one  in  ten.^ 


1  La  syphilis,  1906,  vol.  iv,  p.  64. 

2  Other  American  authors  agree  that  multiple  chancres  are  relatively  in- 
frequent w^ith  us. 


THE    CHANCRE  225 

But  whether  one  in  ten  or  one  in  three,  the  multiple 
chancre  must  be  counted  with,  and  it  is  a  grave  clinical 
error  to  insist  on  the  uniqueness  of  chancre  as  a  diagnostic 
factor. 

The  number  of  multiple  chancres  is  2  in  seventy-eight  per 
cent  of  cases  (Papagaey).  My  father  has  recorded  i  case 
of  II  and  I  of  12  chancres  (4  on  the  left  breast,  8  on  the 
right).  Fournier  has  seen  a  patient  with  23  (7  on  the  left 
breast,  16  on  the  right). 

The  location  of  multiple  chancres  is  almost  exclusively 
genital.  Only  two  per  cent  of  extragenital  chancres  are 
multiple  (Fournier).  Chancres  of  the  breast  are  quite  fre- 
quently multiple.  I  have  seen  one  patient  with  a  chancre 
on  each  lip,  another  with  one  on  the  tongue  and  one  on  the 
lower  lip. 

The  existence  of  multiple  chancres  brings  up  the  question, 
When  does  syphilitic  immunity  begin?  Is  reinoculation  pos- 
sible? 

Although  in  many  instances  the  several  inoculations  are 
indubitably  simultaneous,  in  others  they  doubtless  succeed  one 
another,  perhaps  after  an  interval  of  several  days.  Indeed, 
Queyrat  ^  has  apparently  proven  that  it  is  sometimes  possible 
to  autoinoculate  chancre  if  the  inoculation  is  performed  before 
the  lesion  is  ten  days  old,  and  experimental  inoculation  bears 
this  out. 

Yet,  whether  this  be  proven  or  not,  clinically  speaking 
chancre  is  not  autoinoculable.  When  the  sore  appears  the 
whole  man  is  poisoned  and  cannot  be  reinfected. 

Types  of  Chancre. — The  three  chief  types  of  chancre  are: 

1.  The  eroded  chancre   (Fig.  9). 

2.  The  ulcerated  chancre  (Figs.  10,  11). 

3.  The  indurated  papule  (Fig.  12). 


»  Bull,  de  la  soc.  Franc,  de  derm,  et  de  syph.,  1906,  vol.  xvii,  p.  66. 


226 


THE    INITIAL   LESION 


The  Eroded  Chancre. — From  sixty  to  eighty  per  cent 
of  chancres  assume  this  form.  It  is  most  characteristically 
exemplified  by  chancres  within  the  preputial  cavity. 

The  induration  is  rounded,  circumscribed,  and  thin,  some- 
times so  thin  as  to  be  scarcely  perceptible  except  to  the  most 
delicate  touch  (parchment  chancre). 

Its  color  is  usually  a  dark,  vinous,  or  "  raw-meat  "  red. 
Rarely  it  is  of  a  dusty  gray  color  (the  color  of  lard).  It  may 
be  covered  with  little  petechise. 

Its  surface  is  usually  flat.  It  may  be  a  little  elevated  above 
the  surrounding  integument,  or  a  trifle  sunken  below  it,  or 
surrounded  by  a  slightly  elevated  ring  of  induration. 

The  eroded  surface  is  smooth  and  polished.  It  emits 
a  slight  sero-purulent  discharge.      It  may  be  covered   by  a 

crust  or  a  false  membrane 
p.  :      ( from     infection     by     skin 

cocci). 

The  Ulcerated  Chan- 
cre.— This  is  the  type  of 
chancre  described  by  Hun- 
ter, and  to  it  the  title 
"  Hunterian  chancre "  is, 
therefore,  peculiarly  applic- 
able. It  is  far  less  common 
than  the  eroded  chancre. 

It  has  a  relatively  large 
indurated  base  topped  by  a 
distinct  ulcer.  '  The  ulcer  is 
due  to  extensive  necrosis, 
and  the  necrosis  is  propor- 
tional to  the  interference 
with  circulation;  thus  the 
thinner  induration  forms  an  eroded  chancre,  while  the  more 
nodular  mass  ulcerates.     Exceptionally,  and  doubtless  on  ac- 


FlG.    II. 


-Large  Ulcerated  Hunterian 
Chancre.     (Kaposi.) 


THE    CHANCRE 


227 


count  of  some  unusual  surface  infection,  the  parchment  chan- 
cre ulcerates  deeply. 

The  ulcer  extends  into  the  true  derma.  Its  edges  are  slop- 
ing (not  undermined)  and  give  the  sore  a  sort  of  funnel 
shape;  the  base  is  granulating  and  may  be  covered  by  a  false 
membrane,  the  discharge  is  slight  and  sero-sanguinolent. 


Fig.  12. — Scabies  on  the  Glans  Penis  Resembling  Chancre  of  the  "Indur- 
ated Papule"  Type.     (Piffard.) 
17 


228  THE    INITIAL   LESION 

The  clinical  picture  of  ulcerated  chancre  is  that  of  a  neo- 
plasm eaten  out  by  an  ulcer,  not  that  of  an  ulcer  surrounded 
by  an  inflammatory  ring.  The  neoplasm  may  be  embedded 
within  the  skin;  but  pick  it  up,  and  you  will  realize  that  it  is 
a  distinct  lump  with  an  ulcer  in  its  center. 

The  Indurated  Papule. — This  is  the  rarest  type  of 
chancre.  It  occurs  usually  in  situations  where  the  integument 
is  so  dense  and  thick  as  to  prevent  very  extensive  develop- 
ment of  the  neoplasm.  The  induration  consequently  remains 
a  small,  dark-red,  flat  papule.  As  it  begins  to  heal  the  surface 
becomes  scaly. 

Exceptional  Varieties. — The  induration  may  be  so 
slight  as  to  be  clinically  imperceptible.  Fournier  noted  this 
absence  of  induration  seven  times  in  300  cases. 

As  a  result  the  lesion  appears  to  be  either : 

1.  A  superficial  herpetiform  ulceration  or  group  of  ulcera- 
tions (herpetiform  chancre)  or 

2.  A  grayish  or  silver-white  spot  of  thickened  epithelium. 
This  is  seen  only  on  the  glans  penis. 

Both  these  types  are  extremely  rare. 

On  the  other  hand,  the  induration  may  be  very  ex- 
tensive, and  extend  far  beyond  the  ulceration.  Its  char- 
acteristics remain  the  same  as  those  of  the  usual  smaller 
varieties. 

Complications  of  Chancre. — The  chief  complications  of 
chancre  are : 

1.  Lymphangitis  and  edema. 

2.  Chancroid  (mixed  sore). 

3.  Simple  inflammation. 

4.  Phagedena  (gangrene). 

5.  Transformation  into  a  mucous  papule. 

6.  Vegetations. 

Lymphangitis. — The  lymphangitis  of  chancre  is  by  no 
means  constant.     Corded  lymphatics,  running  from  the  chan- 


THE   CHANCRE 


229 


ere  to  the  adjacent  glands  (e.  g.,  along  the  dorsum  of  the 
penis),  are  not  often  seen. 

But  in  certain  localities,  such  as  the  prepuce  and  the  labia 
majora,  a  great  mass  of  lymphatic  induration  may  surround 
the  chancre,  or  small  similar  masses  may  lie  adjacent.  Such 
a  complication  obstructs  the  lymphatic  flow  and  causes  con- 
siderable edema.  It  is  sometimes  spoken  of  as  indurative 
edema  (Figs.  13,  14). 

"  Mixed  "  Sore. — As  chancroid  itself  is  rare  among  the 
upper  classes,  so  is  the  mixed  sore,  the  combination  of  chancroid 


Fig.   13. — Multiple  Chancroids  Concealing  a  Chancre  ("Mixed"  Sore) 

OF  WHICH  THE  ONLY  EVIDENCE  IS  THE  RiDGE  OF   INDURATION  BaCK  OF  THE 

Corona.     (Kaposi.) 

and  chancre.  Among  the  chancres  seen  in  the  dispensary,  how- 
ever, fully  one  third  are  "  mixed  sores."  A  person  may  be 
infected  with  syphilis  and  with  chancroid  at  the  same  time. 


230  THE    INITIAL    LESION 

In  such  a  case  the  chancroid  develops  first,  and  a  few  weeks 
later  becomes  chancrous  (Fig.  13). 

On  the  other  hand,  infection  with  chancroid  may  occur  in 
the  true  chancre  by  subsequent  inoculation. 

Hence  the  possible  combinations  of  chancre  and  chancroid 
are  three : 

1.  The  chancroid  may  appear,  flourish,  and  be  cured,  and 
from  its  remains  the  chancre  may  arise. 

2.  The  chancroid  may  overlap  and  overshadow  the  chan- 
cre, so  that  the  latter  is  suspected  only  from  the  induration 
remaining  after  the  sore  heals,  or  proven  by  the  appearance 
of  secondary  syphilitic  lesions. 

3.  A  true  chancre  may  become  chancroidal. 

Of  the  three  types,  the  second  is  the  one  commonly  ob- 
served. The  presence  of  chancre  is  not  even  suspected  until 
the  chancroid  in  healing  begins  to  take  on  a  suspicious  hard- 
ness, or  until  a  roseola  breaks  out  all  over  the  patient.  While 
the  patient  has  an  active  chancroid,  therefore,  one  can  never 
assure  him  he  has  not  true  chancre. 

Inflamed  Chancre. — The  friction  of  clothes,  or  any 
other  form  of  trauma  may  so  irritate  the  chancre  that  it  be- 
comes acutely  inflamed;  yet  this  is  unusual.  As  a  rule,  the 
pyogenic  microbes  have  no  effect  upon  chancre  beyond  encour- 
aging ulceration. 

Gangrenous  and  Phagedenic  Chancre. — The  obstruc- 
tion to  circulation  in  the  indurated  base  of  a  chancre  is  habit- 
ually sufficient  to  excite  desquamation  and  exudation  from  its 
surface.  Exceptionally,  it  is  so  marked  as  to  cause  gangrene 
of  the  dermis.     Such  a  complication  is  of  no  great  importance. 

Phagedena  is  far  rarer  and  far  more  important.  The  an- 
cients used  to  consider  phagedenic  chancre  relatively  common, 
yet  we  almost  never  see  it.  This  is  not  because  syphilis  is  less 
severe,  but  because  diagnosis  is  more  accurate.  We  recognize 
nowadays    the    frequency   of   gumma    of   the  penis    (chancre 


THE    CHANCRE 


231 


redux),  and  the  imminent  prospect  of  phagedena  in  this  lesion 
as  well  as  its  occurrence  (much  less  than  of  yore)  as  a  com- 
plication of  chancroid. 

Indeed,  the  occurrence  of  phagedena  is  presumptive  evi- 
dence that  the  sore  is  not  chancre. 

I  have  seen  but  two  cases  of  true  phagedenic  chancre,  one 
in  clinic,  one  in  private.  The  history  of  the  latter  is  as  fol- 
lows : 

Case  XXVII. — May  4,  1906. — Male,  aged  twenty-six,  exhib- 
its a  large  necrotic  ulcer  which  has  destroyed  almost  the  whole 
right  half  of  the  upper  lip  and  is  advancing  rapidly.  The  ulcer 
began  two  months  ago  as  a  "pimple"  (cause  unknown),  which 
refused  to  heal  for  about  six  weeks,  and  then  suddenly  began  to 
spread  and  destroy  the  lip.  He  consulted  a  physician,  who  saw 
a  macular  eruption,  which  has  since  faded  and  has  never  been 
observed  by  the  patient.  Mixed  treatment  was  accordingly  ad- 
ministered, but  it  ruined  the  digestion  without  controlling  the 
lesion,  and  the  patient  was  therefore  brought  to  me. 

Except  some  tender  submaxillary  glands  and  a  superficial 
ulcer  on  the  left  tonsil,  I  find  no  lesions  but  the  lip  ulcer,  which 
is  very  foul  and  manifestly  progressing.  It  extends  from  the 
premaxillary  fold  to  the  angle  of  the  mouth,  and  has  destroyed 
the  lip  internally  up  to  the  alveolar  reflexion  of  the  mucous  mem- 
brane, externally  to  within  a  quarter  of  an  inch  of  the  nose.  The 
patient  is  clean  looking,  has  no  bad  habits,  and  no  knowledge  of 
how  he  acquired  the  sore.  He  has  lost  twenty  pounds,  suffers 
such  excessive  pain  in  the  lip  that  he  neither  sleeps  nor  eats, 
and  is  extremely  weak  and  anemic. 

A  smear  ^  reveals  Spirocheta  pallida  and  various  cocci.  I 
stopped  internal  treatment  to  give  the  digestion  a  rest,  advised 
local  applications  of  potassium  permanganate,  and  administered 
two  hypodermic  injections  (0.3  c.c,  fifty  per  cent  gray  oil  =  0.15 
c.c.  metallic  mercury  in  each  dose)  on  successive  days.  Both 
injections  were  excruciatingly  painful,  but  did  not  salivate.  A 
week  later  I  gave  him  double  the  dose  (0.6  "cc).  In  another 
week  the  digestion  was  much  improved,  so  iodid  of  potassium 

>  By  Dr.  Henry  Brooks. 


232 


THE    INITIAL    LESION 


was  prescribed;  no  injection.  At  the  end  of  three  weeks  both 
tonsils  had  ulcerated,  but  were  improving  rapidly.  The  lip  was 
worse;  iodid  increased;  injection  of  lipiodol,  4  c.c,  and  gray  oil, 
1.3  c.c;  local  (applications  of  argyrol  (which  proved  more  sooth- 
ing than  anything  else).  After  this  the  patient  was  mildly  sali- 
vated, and  no  further  injections  were  given.  Iodid  was  run  up 
rapidly.  On  June  7th  he  reached  255  drops  a  day,  and  the  diges- 
tion gave  out  so  completely  that  I  bade  him  stop,  though  the 
ulcer  was  not  under  control.  Meanwhile  he  had  lost  a  pound 
a  da}'  in  the  past  month.  His  normal  weight  was  150  pounds; 
now  102.  The  ulcer  had  advanced  about  an  eighth  of  an  inch 
all  around. 

Salivated,  his  power  of  digestion  utterly  gone,  unable  to  sleep 
for  pain  and  weakness,  and  with  the  ulcer  still  slowly  progress- 
ing, it  took  all  the  poor  lad's  fortitude  to  accept  my  assurance 
that  the  end  was  at  hand.  But  in  a  week  healing  had  begun,  and 
he  felt  so  much  better  that  the  iodid  was  resumed  at  120  drops 
a  day,  and  increased  in  two  weeks  to  the  former  maximum,  then 
stopped.  On  July  5th  he  had  .a  ravenous  appetite,  weighed  126 
pounds,  and  the  lip  was  halfway  healed,  leaving  a  terrible  de- 
formity. Yet  the  patient  is  so  delighted  to  be  rid  of  the  pain,  the 
disgusting  fetor,  the  everlasting  slough,  that  he  could  scarcely 
be  happier  were  he  entirely  well. 

(Within  two  months  he  had  a  large  gumma  of  the  shin,  which 
was  ten  weeks  in  healing.  Since  then — to  July,  1907 — he  has 
remained  well.) 

Such  is  the  true  phagedenic  chancre — one  of  the  most 
virulent  types  of  the  so-called  "  malignant  precocious  syphilis," 
and  eminently  deserving  of  the  name. 

Whether  this  phagedena  is  due  to  mixed  infection  (and 
comparable  to  noma  and  to  fulminating  gangrene  of  the  geni- 
tals) or  to  the  same  conditions  that  produce  phagedena  in  ter- 
tiary lesions  I  do  not  know.  But,  like  tertiary  phagedena,  it  is 
virulent  in  onset,  usually  self-limited  under  almost  any  treat- 
ment, and  to  be  combated  by  hygiene  ^  and  mixed  treatment. 

*  The  hygienic  possibilities  in  the  cited  case  were  almost  nil,  for  the  patient 
had  spent  all  his  money  and  could  scarcely  masticate  or  swallow  his  food. 


THE    CHANCRE 


233 


Transformation  into  a  Mucous  Papule. — Chancre 
upon  the  mucous  membrane  or  between  moist  folds  of  skin 
may,  at  the  time  of  the  first,  general,  secondary  outbreak, 
become  a  typical  mucous  papule.  The  fact  requires  no  further 
comment. 

Vegetations. — Soft  warts  may  surround  the  chancre. 
Their  presence  is  accidental,  and  can  scarcely  be  called  a  com- 
plication. 

Duration. — The  chancre  usually  lasts  four  to  six  weeks, 
though  some  trace  of  induration  may  remain  many  months. 

Reiiidtiration  of  the  chancre,  which  simply  means  recur- 
rence of  syphilitic  inflammation  (secondary  or  tertiary)  in  a 
chancre  partially  or  wholly  cicatrized,  may  prolong  its  dura- 
tion indefinitely. 

Fournier  relates  that  he  has  seen  a  chancre  run  its  whole 
course  in  two  weeks.  This  must  be  about  the  minimum.  Yet 
patients  will  often  say  that  their  chancres  only  lasted  a  few 
days,  for  they  are  careless  observers.  Their  testimony  merely 
bears  witness  to  the  clinical  insignificance  and  painlessness  of 
this  lesion  so  fraught  with  grave  consequences. 

Diagnosis. — ^The  diagnosis  of  chancre  depends  so  largely 
upon  the  character  of  the  adjacent  adenitis  that  it  is  deferred 
to  a  subsequent  chapter. 

Prognosis. — The  prognosis  is  excellent.  The  chancre  will 
get  well  spontaneously,  and  little  can  be  done  to  hasten  its 
healing. 

As  to  general  prognosis,  as  the  chancre  is  syphilitic,  so  is 
the  patient. 

Treatment. — If  the  chancre  is  not  ulcerated  a  daily  wash 
with  warm  water,  protection  from  friction  of  the  clothes,  and 
the  application  of  any  simple  dusting  powder  is  all  the  treat- 
ment it  needs. 

If  ulcerated,  black  wash  (lotion  nigra)  is  the  customary 
application,  and  I  know  none  better. 


ly 


234 


THE    INITIAL    LESION 


If  it  is  a  mixed  sore,  treat  the  chancroid. 

If  inflamed,  wet  dressings  of  carboHc-acid  solution,  i :  200. 

If  phagedenic,  twenty  per  cent  argyrol,  and  vigorous  mixed 
treatment. 

The  general  treatment  of  syphilis  is  not  often  begun  until 
the  chancre  is  almost  healed.  Begun  earlier  it  encourages 
healing,  but  this  is  a  matter  of  no  moment. 


CHARACTERISTICS  OF  CHANCRE  IN  VARIOUS 
LOCATIONS 

Chancre  of  the  Male  Genitals. — Chancre  of  the  glaiis  penis 
is  small,  thin,  and  erosive.  When  multiple,  they  may  (rarely) 
simulate  a  group  of  herpetic  papules  (herpetiform  chancre). 

Chancre  of  the  coronary  sulcus  is  large  and  thick.  It  is 
usually  associated  with  plaques  of  lymphangitis;  indeed,  it  is 
not  rare  for  this  lymphangitis  to  surround  the  penis  like  a 
collar  (Fig.  13). 

Chancre  of  the  interna!  surface  of  the  prepuce  follows  the 
usual  erosive  type.  At  the  oritice  its  lymphangitis  may  cause 
inflammatory  phimosis. 

Chancre  at  the  meatus  is  characterized  by  a  dark  red  tume- 
faction of  one  or  both  lips.  The  erosion  may  be  entirely 
within  the  urethra  or  it  may  extend  over  the  surface  of  the 
glans.  The  diagnosis  of  meatus  chancre  is  made  by  palpa- 
tion. Grasp  the  tip  of  the  glans  above  and  below  and  you 
immediately  appreciate  the  characteristic  elastic  induration. 

Chancre  of  the  skin  of  the  penis  is  large,  superficial,  and 
crusted.  On  removal  of  the  crust  it  may  look  as  though 
the  edges  of  the  ulcer  were  sharp  and  undermined,  like 
those  of  chancroid,  but  close  inspection  will  prove  that  they 
are  not. 

Chancre  of  the  pubes  is  usually  large  and  deeply  ulcer- 
ated. 


Fi-.  I. 


Fig.  2. 

PLATE     IV. — EXTR.'\GENIT.A.L    Ch.\NCRE. 

Fig.   I. — Chancre  of  breast.     (Musee,  St.  Louis.) 
Fig.  2. — Chancre  of  tonsil.     (Musee,  St.  Louis.) 


CHARACTERISTICS    OF    CHANCRE  235 

Chancre  of  the  scrotum  is  usually  eroded,  with  marked  in- 
duration. 

Urethral  Chancre. — Chancre  of  the  urethra  is  far  from 
rare.  Among  549  cases  of  penile  chancre  examined  I  have 
found  62  urethral  chancres.^  They  were  all  in  the  terminal 
inch  of  the  urethra,  except  three.  One  of  these  was  in  the  scro- 
tal portion  of  the  urethra,  the  other  two  in  the  pendulous  por- 
tion. Each  of  the  three  was  first  seen  by  me  at  the  time  of  the 
secondary  outbreak.  In  two  of  them  the  mass  of  induration 
could  be  very  distinctly  felt  externally.  The  third,  a  chancre  of 
the  penile  portion,  could  be  plainly  seen  through  the  urethro- 
scope as  a  dark-red  neoplasm,  but  it  was  too  near  to  healing  to 
be  felt  externally. 

One  of  these  chancres  was  so  large  as  to  cause  chordee 
and  great  dysuria. 

As  a  rule,  however,  the  only  symptom  noticed  by  the  pa- 
tient is  a  very  slight  urethral  discharge.  This  he  mistakes 
for  a  simple  urethritis  (or  he  may  overlook  it  entirely).  Pain 
on  urination  at  the  inflamed  point  is  usually  slight. 

Hence  it  is  prudent  to  suspect  of  urethral  chancre  (i) 
every  patient  zmth  simple  iirethritis,  and  (2)  every  patient 
in  early  secondary  syphilis  vi'ho  denies  the  existence  of 
chancre. 

Palpation  of  the  glans  from  before  backward  reveals 
chancres  in  that  region.  Lateral  palpation  of  the  urethra  re- 
veals deeper  ones.  The  urethroscope  shows  a  livid  mass  cov- 
ered with  false  membrane. 

Chancre  of  the  Female  Genitals. — The  regions  involved 
in  order  of  frequency  are  the  labia  majora,  the  labia  minora 
and  fourchette,  the  cervix  uteri,  the  region  about  the  vestibule, 
urethra,  and  introitus,  the  vaginal  wall  (extremely  rare). 

Chancre  of  the  labium  majiis  is  usually  large  and  ulcer- 

'  Yet  I  feel  that  this  (eleven  per  cent)  is  far  above  the  general  average  of 

frequency. 


?36 


THE    INITIAL   LESION 


ated,    often   surrounded   by   a  mass   of   matted   lymphangitis 
(Fig.  14). 

Chancre  of  the  cervix  may  surround  the  cervical  canal  or 
may  invade  one  lip  only.     It  is  large,  and  covered  v^ith  false 


Fig.    14. — Chancre   of  Labixim  near  Fourchette:   Indurative  Edeila  of 
Vulva:  Papulo-xiacular  Syphilid.     (Piffard.) 


membrane  around  which  the  chancre  extends  in  a  thick,  pur- 
plish rim.     Its  secretion  is  slight,  the  pain  nil.     Hence  the 


CHARACTERISTICS   OF   CHANCRE  237 

patient  never  complains  of  it;  one  must  search  in  order  to 
discover  it.  The  induration  is  scarcely  palpable  on  account 
of  the  density  of  the  cervical  tissue. 

Chancre  clsezuhere  within  the  female  genitals  is  usually 
small  and  parchmentlike.  In  the  vestibule  and  about  the  ure- 
thra it  may  excite  lymphangitis,  but  in  the  vagina  its  indu- 
ration dwindles  down  to  almost  nothing.  Indeed,  the  clinical 
rarity  of  vaginal  chancres  is  believed  to  be  due  to  their  being 
overlooked. 

Extragenital  Chancre. — As  is  shown  in  the  tables  on  page 
56  extragenital  chancre  is  much  more  common  in  and  about  the 
mouth  than  anywhere  else.  Chancre  of  the  lips  is  commonest 
of  all.     The  lower  lip  is  most  frequently  affected. 

Buccal  Chancre. — Chancre  of  the  lip  (Plate  V,  Figs.  2, 
3,  also  Fig.  17)  varies  in  size  from  the  smallest  papule  to  a 
great  ulcerated  mass.  Usually,  however,  it  is  large,  prominent, 
crusted,  and  extremely  distressing  to  its  possessor. 

Chancre  of  the  tongue  may  appear  on  any  part  of  that 
organ,  but  is  commonest  on  the  dorsum  toward  the  tip.  It  is 
usually  quite  large,  and  the  lymphangitis  may  infiltrate  the 
surrounding  tissue  widely. 

Chancre  of  the  tonsil  (Plate  IV,  Fig.  i)  produces  the  gen- 
eral and  local  symptoms  of  a  mild  tonsilitis.  There  is  lassi- 
tude, often  cjuite  a  sharp  fever,  and  considerable  local  pain  on 
deglutition. 

Inspection  reveals  a  general  enlargement  of  the  tonsil.  It 
is  covered  with  a  thick,  adherent,  false  membrane  under  which 
the  surface  is  flat  and  eroded  or  exulcerated.  All  the  sur- 
rounding tissues  are  swollen.  Palpation  reveals  marked  indu- 
ration. 

Exceptionally  the  tonsillar  chancre  is  a  small  eroded 
papule. 

Chancre  of  the  giun  is  extremely  rare.  It  forms  an  eroded 
induration  surrounding  the  roots  of  several  teeth. 


238  THE    INITIAL   LESION 

Tegumentary  Chancre. — Chancre  of  the  skin  is,  gener- 
ally speaking,  quite  large  and  often  ulcerated. 

Chancres  of  the  female  breast  (Plate  IV,  Fig.  2),  often 
multiple,  usually  affects  the  areola. 

Chancre  of  the  finger  is  rarely  seen  except  upon  doctors 
and  midwives ;  but  among  them  it  is  sadly  common.  Its  loca- 
tion, four  times  in  five,  is  about  the  nail  of  the  index  finger. 
Such  types  as  the  fungating  chancre  (Taylor),  the  peri- 
ungual, and  the  hypertrophic  chancre  (Fournier)  are  suffi- 
ciently described  by  their  titles. 

The  sore  is  usually  large,  purple,  fungating,  and  scabbed. 
The  induration  is  marked,  but  cannot,  on  account  of  their  den- 
sity, be  isolated  from  the  surrounding  tissues. 

Vaccinal  chancre  need  only  be  mentioned. 

A)ial  chancre  is  fairly  common  among  women.  It  is  often 
hidden  within  the  anus,  and  lying  in  a  fold  may  assume  a 
duplex- shape,  like  the  leaves  of  a  book  {chancre  en  feuillets  de 
livre).     Anal  chancre  causes  some  pain  on  defecation. 

Rectal  chancre  is  rare,  symptomless,  almost  always  over- 
looked.    It  has  no  special  characteristics. 

Chancre  of  the  eyelid  is  rare. 

Chancre  of  the  conjunctiva  is  rarer  still.  Occurring  near 
one  of  the  commissures  it  causes  dense  induration  of  both 
lids,  and  by  pulling  these  apart  we  find  the  ulcer  between. 
Elsewhere  on  the  conjunctiva  (usually  the  palpebral)  it  is 
small  and  erosive.  There  is  always  an  associated  acute  con- 
junctivitis. 

THE    ADENITIS    OF    CHANCRE 

Syphilitic  inflammation  of  the  group  of  lymph  nodes  adja- 
cent to  the  chancre  is  part  of  the  initial  lesion.  .  It  is  as  con- 
stant and  typical  as  the  chancre  itself.  Indeed,  Fournier  failed 
to  find  it  only  thrice  in  5,000  cases;  he  suggests  that  congen- 


PLATE    V. 


PLATE   \'. — Extragenital  Chancre. 

Fig.  I. — Chancre  of  the  lip:  erosive  type,  deeply  split.     (Musee,  St.  Louis.) 
Fig.  2. — Two  chancres  of  the  tongue.     (Musee,  St.  Louis.) 
Fig.  3. — Chancre  of  the  lip:  crusted.     (Musee,  St.  Louis.) 


THE   ADENITIS   OF    CHANCRE  239 

ital  absence  of  the  inguinal  glands  may  explain  the  absence  of 
adenitis  in  these  cases. 

The  nodes  affected  are  those  fed  from  the  site  of  the  chan- 
cre, thus : 


Ingfuinal. 


LOCATION    OF    CHANCRE  ADJACENT    ADENITIS 

Genitals,       anus,        buttocks, 

thigh,  leg,  foot. 

Lip  or  chin.  Submaxillary. 

Tongue.  Subhyoid. 

Tonsil.  ■  Lateral  cervical. 

Eye — near  outer  canthus.  Preauricular. 

Eye — near  inner  canthus.  Submaxillary. 

Finger,  hand,  forearm.  Epitrochlear  and  axillary. 

Arm,  breast.  Axillary. 

Chancre  of  the  cervix  uteri  gives  no  external  adenitis, 
though  doubtless  the  pelvic  nodes  are  affected. 

Inguinal  adenitis  may  be  bilateral  or  unilateral ;  if  the  lat- 
ter, it  is  usually  on  the  side  corresponding  to  the  chancre. 
Exceptionally  the  lymphatics  so  anastomose  that  the  adenitis 
is  on  the  opposite  side  (crossed  bubo) .  As  a  rule,  however, 
both  sides  are  affected. 

Symptoms. — The  adenitis  (bubo)  appears  in  the  second 
week  after  the  appearance  of  the  chancre,  usually  on  or  about 
the  tenth  day.  It  reaches  maturity  in  two  or  three  days,  and 
presents  the  following  characteristics :  multiplicity,  moderate 
size,  absence  of  periadenitis  and  of  all  acute  inflammation, 
hardness,  slow  resolution. 

Multiplicity. — There  is  always  a  group  of  nodes  in- 
volved; indeed,  inguinal  adenitis  usually  shows  involvement 
of  a  group  in  each  groin,  but  the  one  rather  more  enlarged 
than  the  other. 

This  group,  or  pleiad,  as  Ricord  appropriately  termed  it. 


240  THE    INITIAL    LESION 

is  jnade  up  of  one  (rarely  more)  large  node  surrounded  by  a 
group  of  lesser  ones  (clinically  the  large  node  often  predomi- 
nates the  scene,  the  lesser  ones  being  scarcely  discernible). 

Size. — The  larger  node  scarcely  attains  the  size  of  a  cherry 
and  may  be  much  smaller ;  the  lesser  ones  are  the  size  of  peas. 

Absence  of  Inflammation.- — Unless  there  is  mixed  in- 
fection the  nodes  are  neither  painful  nor  tender.  They  are 
freely  movable  beneath  the  skin,  upon  the  subjacent  parts,  and 
upon  one  another.^  The  skin  over  them  is  not  discolored; 
they  do  not  suppurate.  This  complete  absence  of  periadenitis 
is  one  of  their  most  striking  characteristics. 

Hardness. — "  The  hardness  of  the  nodes  is  the  hardness 
of  the  chancre  " ;  such  is  the  routine  statement.  The  clinical 
facts  do  not  quite  bear  it  out.  Though  the  nodes  may  be  as 
hard  as  the  chancre,  and  when  so  are  typical,  in  the  larger 
number  of  cases  they  are  distinctly  more  elastic.  Examina- 
tion of  a  series  of  patients  will  impress  this  characteristic. 

Slow  Resolution. — The  great  virtue  of  syphilitic  bubo 
is  that  it  persists  many  weeks  after  the  chancre  has  disap- 
peared and  may  lead  to  the  discovery  of  the  scar  of  a  healed 
chancre.     It  usually  persists  three  or  four  months. 

Unusual  Varieties.  —  The  bubo  may  be  abnormal,  inflamed, 
or  "  mixed." 

Abnormal  Bubo. — Exceptionally  the  bubo  consists  of  a 
single  very  large  gland,  or  the  large  gland  is  altogether  lacking. 

Inflamed  Bubo. — Inflamed  bubo  is  much  more  common 
than  inflamed  chancre.  The  pyogenic  bacteria  multiply  upon 
the  chancre  and  from  it  enter  the  lymph  current,  yet  may  not 
cause  much  local  irritation.  The  common  clinical  causes  of 
inflamed  bubo  are  genital  filth  and  cohabitation. 

The  bubo  of  labial  or  buccal  chancre  is  habitually  a  large, 
tender,  inflamed  mass. 

1  Unless  they  are  greatly  inflamed,  in  which  case  they  adhere  tightly  to  one 
another. 


THE    ADENITIS    OF    CHANCRE  '     241 

As  a  result  periadenitis  occurs ;  the  nodes  become  matted 
together  and  are  painful  and  tender.  Suppuration  is  ex- 
tremely rare,^  and — singular  fact — when  it  does  occur,  it 
appears  to  spare  the  nodes  themselves ;  evacuate  the  pus,  and 
the  syphilitic  nodes  remain.  The  condition  is  a  suppurating 
periadenitis. 

"  Mixed  "  Bubo. — Syphilitic  adenitis  may  be  complicated 
by  chancroid  or  by  tuberculosis. 

Chancroid  and  chancre  combine  to  make  a  "  mixed  "  sore 
and  a  "  mixed  "  bubo.  In  both  instances  the  characteristics 
of  the  chancroidal  lesion  overshadow  the  other. 

Tuberculosyphilitic  nodes  I  have  never  seen.  They  are 
said  to  assume  the  tubercular  type. 

Diagnosis. — The  typical  group  of  one  large  uninflamed 
gland  surrounded  by  a  lot  of  little  ones — all  of  them  hard, 
insensitive,  and  not  adherent— is  so  characteristic  that  a  dis- 
cussion of  its  differentiating  characteristics  is  all  but  super- 
fluous. 

Certain  varieties  of  herpes  or  balanitis  excite  a  bubo  quite 
similar  to  that  of  syphilis;  but  the  exciting  lesion  is  so  dis- 
similar that  a  mistake  is  scarcely  possible. 

The  insensitive,  hard,  movable  nodes  of  syphilis  can 
scarcely  be  confused  with  the  inflamed,  tender,  adherent  nodes 
of  chancroid ;  though,  as  we  have  already  said,  the  latter  may 
conceal  the  former. 

The  bubo  is  readily  diagnosed  and  forms,  as  we  shall  see, 
one  of  the  most  important  means  of  diagnosing  chancre. 

Treatment. — Neither  demanded  nor  available. 

>  Foumier  records  1.6  per  cent  of  suppurations  in  the  clinic,  0.6  per  cent  in 
private  practice. 


CHAPTER    XVII 
DIAGNOSIS  OF   THE  INITIAL  LESION 

In  order  to  diagnose  chancre,  study  its  bubo.  The  cHn- 
ical  characteristics  of  chancre  are  doubtful ;  how  often  only 
the  syphilologist  knows,  while  the  nodes  are  usually  pathog- 
nomonic. 

-  Moreover,  the  chancre  may  be  insignificant,  or  may  have 
healed  before  the  patient  comes  under  observation :  examine 
the  nodes  carefully  and  you  will  usually  light  upon  a  group 
that  leads  to  the  site  of  chancre. 

In  order  of  importance,  therefore,  the  diagnostic  features 
of  primary  syphilis  may  be  classified  thus : 

1.  Character  of  the  sore. 

2.  Character  of  the  bubo. 

3.  Autoinoculation. 

4.  Examination  for  spirocheta. 

5.  History  and  confrontation. 

6.  The  test  of  time.     Development  of  secondary  syphilis. 
Character  of   the   Sore. — It  is   usually  single,   small. 

uninflamed,  indurated,  eroded  rather  than  ulcerated,  smooth 
and  glistening  of  surface,  dark  red  in  color,  not  excavated. 

Moreover,  any  sore  lasting  more  than  a  zceek  moy  be 
chancre. 

Character  of  the  Bubo. — Need  not  be  repeated. 

Autoinoculation. — Syphilitic   autoinoculation   is  barely 

possible,  and  produces  only  an  insignificant  little  papule,  while 

chancroid  produces  a  typical  chancroidal  ulcer. 
242 


DIAGNOSIS    OF    THE    INITIAL    LESION  243 

Examination  for  Spirocheta. — No  one  but  a  specially 
trained  bacteriologist  should  be  trusted  for  an  opinion.  A 
positive  report  should  be  given  not  too  much  weight;  a  nega- 
tive report  means  nothing. 

History  and  Confrontation. — An  accurate  history  of  a 
single  sexual  exposure  three  to  six  weeks  before  the  appear- 
ance of  the  sore  is  a  presumption  in  favor  of  its  being  chancre, 
and  if  the  examination  of  the  suspected  partner  reveals  infec- 
tious secondary  lesions  upon  her,  this  confrontation,  as  it  is 
termed,  adds  great  weight  to  the  presumption.  But  the  most 
perfect  history  cannot  constitute  objective  certainty. 

Negative  history  or  negative  confrontation,  on  the  other 
hand,  are  scarcely  to  be. considered  in  evidence.  Just  as  syphi- 
lis frequently  is  not  acquired  after  exposure  to  a  manifestly 
infected  source,  so  is  it  sometimes  acquired  by  exposure  to  an 
apparently  irreproachable  source.  The  minutest  examination 
of  the  infectress  may  fail  to  reveal  the  slightest  infectious 
lesion. 

Requirements  for  Diagnosis. — To  suspect  a  chancre  is 
easy;  to  prove  it  extremely  difficult.  Though  always  as- 
suming a  most  guarded  attitude,  I  have  been  deceived  often 
enough  to  realize  that  the  diagnosis  of  syphilis  from  chancre 
must  not  rest  upon  anyone's  opinion;  but  upon  objective  cer- 
tainty. 

Such  certainty  can  be  attained  only  by  the  concurrence  of 
four  different  factors,  viz. : 

1.  A  typical  sore. 

2.  A  typical  adenitis. 

3.  Negative  autoinoculation  (and  search  for  the  Ducrey 
bacillus). 

4.  Positive  spirocheta  finding  by  an  expert. 

Many  chancres  fail  to  come  up  to  these  requirements;  bet- 
ter leave  the  doubt  open  until  the  advent  of  secondary  lesions 

proves  the  case.     This  is  peculiarly  necessary  if  no  real  expert 
18 


244 


DIAGNOSIS    OF    THE    INITIAL    LESION 


on  spirocheta  is  available.  Better  no  diagnosis  at  all  than  one 
founded  on  inaccurate  microscopic  evidence. 

One  other  thing  is  necessary  before  treatment  is  begun ; 
be  sure  that  the  patient  is  convinced  he  has  syphilis.  Until  he 
is  absolutely  persuaded  of  this,  sentence  should  be  suspended; 
for  it  requires  a  firm  belief  to  carry  him  through  the  long 
months  of  treatment;  and  the  worst  thing  that  could  happen 
to  him  is  to  take  treatment  just  long  enough  to  control  the 
first  outbreak,  and  then  to  quit. 

The  Test  of  Time. — Most  patients  must  await  the  advent 
of  secondary  lesions  before  their  syphilis  can  be  absolutely 
proven. 


DIFFERENTIAL   DIAGNOSIS   OF   GENITAL   CHANCRE 

Herpes. — A  beginning  chancre  may  be  mistaken  for  sim- 
ple herpes  progenitalis 
(Fig.  15). 

The  typical  herpetic 
eruption,  consisting  of 
scattered  superficial  vesi- 
cles and  ulcerations  sur- 
rounded (and  preceded) 
by  an  erythematous  blush, 
burning  and  itching,  can 
scarcely  be  confused  with 
chancre;  but  the  single 
herpetic  ulcer,  set  on  a 
base  of  inflammatory  in- 
duration and  associated 
with  mild  inguinal  ade- 
nitis, may  closely  mimic 
chancre. 

Fig.  15.-HERPES  Progenitalis  There  are  three  distin- 

(Baerensprung  and  Hebra).  guishing    characteristics  : 


DIAGNOSIS   OF   GENITAL   CHANCRE  245 

Induration  is  extremely  rare  with  herpes;  it  is  constant 
with  chancre.  . 

Adenitis  is  extremely  rare  with  herpes ;  constant  with 
chancre. 

The  contour  of  the  lesions  differs.  The  herpetic  ulcer  is 
made  up  of  many  minute  lesions,  and  its  edge  is,  there- 
fore, a  series  of  many  little  intersecting  segments  of  cir- 
cles; it  is  polycyclic  and  micr-ocyclic  (as  Fournier  has  it). 
The  contour  of  chancre,  however  irregular,  is  never  thus  scal- 
loped. 

But  all  these  signs  may  fail  us;  herpes  and  chancre  may 
even  coexist.  The  final  test  is  time.  Watch  the  evolution  of 
the  lesion.  If  it  gets  well  within  ten  days,  leaves  no  indu- 
rated scar,  no  chronic  adenitis,  it  is  not  chancre.  Otherwise 
one  must  await  the  secondaries. 

Scabies.  —  An  ulcerated  or  papular  lesion  of  scabies  (Fig. 
12)  on  the  genitals  may  most  precisely  mimic  chancre.  As 
with  herpes,  there  may  be  slight  inflammatory  infiltration  of 
its  base  and  enlargement  of  the  adjacent  glands. 

The  diagnosis  rests  on  the  discovery  of  scabies  elsewhere 
in  the  body  and  the  rapid  cure  of  the  lesion  under  sulphur 
ointment. 

Chancroid. — The  essential  difference  between  chancre  and 
chancroid  is  that  the  former  is  a  neoplasm  the  surface  of  which 
may  be  more  or  less  ulcerated,  while  the  latter  is  an  ulcer 
pure  and  simple.  The  chancroid  may  conceal  a  coexisting 
chancre. 

Gumma. — The  three  disorders  considered  above  imitate 
the  small  ulcerative  chancre.  Gumma  of  the  penis — chancre 
redux  (page  481),  it  is  very  appropriately  termed — imitates 
the  large,  thick  type  of  chancre  (Hunterian  chancre). 

With  gumma  there  is  history  of  syphilis;  with  chancre 
history  of  exposure.  With  gumma  the  concurrence  of  ingui- 
nal  adenitis   is   rare  and   accidental;   with   chancre,   constant 


246 


DIAGNOSIS    OF   THE    INITIAL    LESION 


and  characteristic.     Gumma  is  an  induration  which  ulcerates; 
chancre  is  an  erosion  which  becomes  indurated. 

Summary. — The  following  table  sums  up  the  differential 
diagnosis : 


SYPHILITIC 
CHANCRE 

I. —  History. 
— Sexual  con- 
tact, kissing, 
mediate  infec- 
tion, vaccina- 
tion, etc. 


CHANCROID 

I.  Sexual 
contact. 


Relapsing 


herpes. 


2.  None. 


I.  The  fam- 
ily scratches. 


2.  None. 


2.  Incuiation.  2.   Three   to 

— Two    to    six  seven  days, 
weeks. 

T,.  M  i  c  r  o  -  3.      Strepto-         3.      Nothing         3.     Nothing 

scope  shows. —  bacillus,   not     characteristic.       characteristic. 

Treponema  always. 
often. 


4.  Autoinoc- 
ulahility. — Un- 
certain and 
atypical. 


5.  Commence- 
ment:— Begins 
as  an  erosion 
or  a  papule, 
and  remains  an 
erosion  or  ul- 
cerates. 

6.  N  u  m  - 
her.  —  Usually 
unique  or  si- 
multaneously 
multiple;  rare- 
ly multiple  by 
successive  au- 
toinoculation; 
never  confluent. 


4.  Produces 
typical  chan- 
croid on  third 
day.  From 
this  strepto- 
bacillus  may 
be  readily  ob- 
tained. 

5.  Begins  as 
a  pustule  or  ul- 
cer, and  invari- 
ably remains  as 
an  ulcer. 


6.  Usually 
multiple,  both 
simultaneously 
and  by  succes- 
sive autoinoc- 
ulation;  often 
confluent. 


4.  No. 


4.  Produces 
a  cuniculus,  per- 
haps. 


5.  Begins  as 
a  group  of  ves- 
icles, rarely  as 
a  single  vesicle, 
and  becomes 
an  ulcer. 

6.  Usually 
multiple,  si- 
multaneously 
and  by  succes- 
sive crops  of 
vesicles;  some- 
times confluent. 


5.  Begins  as 
a  papule;  be- 
comes ecthy- 
matous. 


6.  Usually 
multiple  and 
scattered  over 
the  body.  Not 
confluent. 


Syphi- 


Utic. 


2.  None. 


3.     Nothing 
characteristic. 


4.  No. 


5.  Begins  as 
a  tumor  which 
ulcerates 
later. 


6.  Usually 
single.  Con- 
fluent if  mul- 
tiple. 


DIAGNOSIS   OF    GENITAL    CHANCRE 


247 


SYPHILITIC 

CHANCRE 

CHANCROID 

HERPES 

SCABIES 

GUMMA 

7.     Physiog- 

7. (a)  Shape: 

7.  (a)  Shape: 

7.  (a)  Shape: 

7.  (a)  Like 

nomy.  —  (a) 

round,  oval,  or 

irregularly 

round  or  oval. 

chancre. 

Shape:    round, 

unsymmetrical- 

rounded,    vwth 

oval,    or    sym- 

ly irregular. 

borders    de- 

metrically    ir- 

with border  de- 

scribed by  seg- 

regular. 

scribed  by  seg- 
ments of  large 
circles. 

ments  of  small 
circles   left   by 
the      confluent 
vesicles. 

(6)  Lesion  is 

(b)  Always  a 

(b)  Ulcer  usu- 

(b)     Ulcera- 

(b)    Like 

habitually  flat, 

true  ulcer,  ex- 

ally superficial; 

tion     slight. 

chancre. 

capped  by  ero- 

cavated,     hol- 

sometimes     in 

Ecthymatous. 

sion  or  superfi- 

lowed out. 

solitary   herpes 

cial  ulceration; 

there  is  but  one 

or  scooped  out; 

absolutely    cir- 

or a  deep,  fun- 

cular     vesicle. 

nel-shaped    ul- 

There    are 

cer  with  sloping 

usually    neigh- 

edges.     Some- 

boring   groups 

times  the  pap- 

of   vesicles    to 

ule  is  dry  and 

clear     up     the 

scaly. 

diagnosis. 

(c)  Edges: 

(c)  Edges: 

(c)Edges: 

(c)  Edges: 

(c)    Edges: 

sloping  and  ad- 

sharply       cut, 

sharp,  not  un- 

like herpes. 

Hke    chancre. 

herent,     some- 

abrupt,     often 

dermined. 

times      promi- 

undermined. 

nently  elevated. 

(d)    Bottom: 

(d)    Bottom: 

(d)    Bottom: 

(cT)   L  i  k  e 

(d)    Like 

smooth,     shin- 

uneven, warty. 

even,      inflam- 

herpes. 

chancre. 

ing. 

irregular,  with- 
out luster. 

matory. 

(e)  Color: 

(e)  Color: 

(e)  *  L  i  k  e 

(e)    Like 

(e)     Like 

somber,    dark- 

yellow,  tawny. 

chancre. 

ecthyma. 

chancre. 

ish   red,    gray. 

false-mem- 

or  black;  some- 

branous-  look- 

times Hvid  and 

ing;  sometimes 

scaly,  occasion- 

bright. 

ally  scabbed. 

(/)  Secretion: 

(/)  Secretion : 

(/)  Secretion: 

(/)  Secretion: 

(/)    Like 

slight,     sero- 

abundant    and 

slight,  scro- 

very  sHght. 

chancre. 

sanguinolent. 

purulent. 

purulent. 

unless  irritation 

provokes    sup- 

puration. 

248 


DIAGNOSIS    OF   THE    INITIAL    LESION 


8.  Inf  1  am- 
matory  indura- 
tion, capable  of 
being  produced 
by  the  same 
causes  as  in 
chancroid,  and 
behaving  in  a 
precisely  simi- 
lar manner. 


SYPHILITIC 
CHANCRE 

8.  Induration.  8.  Absent  in  8.  Inf  lam-  8.  Same 
— Constant,  typical  cases,  matory  indura-  herpes, 
parchmentlike 
and  very  faint, 
or  cartilaginous 
and  extensive, 
terminating 
abruptly,  not 
shading  off  into 
parts  around, 
movable  upon 
parts  beneath 
the  skin,  and 
not  adherent  to 
the  latter:  may 
disappear  in  a 
■  few  days,  usu- 
ally outlasts  the 
sore  and  may 
remain  for 
ntionths. 

g.  Sensitive-         9.  Painful         9.  Beginning         9.  Itch. 
ness. — r Absent,     and  sensitive.       heat. 

10. Duration.         10.       Varies         10.  Rarely         10.  Indefi- 
— At     least     a     from  a  few  days    more  than  ten     nite. 
fortnight.  to  many  weeks,     days. 


CHANCROID 

8.  Absent  in 
typical  cases. 
An  induration 
may  be  caused 
by  irritants  or 
by  inflamma- 
tion. It  is  bog- 
gy, not  elastic, 
shades  off  into 
surrounding  tis- 
sues, is  adher- 
ent to  parts 
around,  disap- 
pears promptly 
on  healing  of 
the  sore,  or  be- 
fore that  time. 


11.  Phage- 
dena.— E  X- 
tremely  rare. 

12.  Lymph- 
an  g  i  t  i  s .  — 
SyphiHtic. 

13.  Lymph- 
adenitis . — 


II.  Rare. 


12.  Inflam- 
matory. 

13.  C  h  a  n  - 
croidal;   or  in- 

SyphiUtic,  con-     flammatory    in 
stant.  one  third  of  all 

cases. 


II.  No. 


12.  Same. 


13.  Rare,  in- 
flammatory. 


II.  No. 


12.  None. 


13.  None. 


GUMMA 

8.  Same  as 
chancre.  In- 
duration al- 
ways exten- 
sive. 


9.  Absent. 

ID.  At  least 
a  fortnight. 
Usually  much 
longer. 

II.  Uncom- 


12.  None. 


13.  None. 


The  final  test  is  the  advent  of  secondary  symptoms. 


DIAGNOSIS    OF    CHANCRE    OF    THE    MOUTH  249 

DIFFERENTIAL   DIAGNOSIS   OF   CHANCRE   OF 
THE   MOUTH 

Chancre  of  the  Lip. — The  following-  table  gives  the  salient 
points  of  differentiation  between  chancre  and  epithelioma : 

CHANCRE  EPITHELIOMA 

1.  Incidence. — Usually  occurs  in  i.  Rare  below  40.  Extremely  rare 
youth.  About  one  third  of  the  pa-  in  women.  Usually  a  history  of  ex- 
tients  are  women.  cessive  smoking. 

2.  Physiognomy. — Surface  flat  and  2.  Surface  irregular,  vegetating: 
shining;  edges  rounded:  does  not  edges  thick,  raised,  everted;  bleeds  at 
bleed  readily.  the  least  touch. 

3.  Adenitis. — Nodes  enlarged  with-  3.  Nodes  enlarge  only  after  several 
in  a  week  or  ten  days.  May  be  ten-  months.  They  enlarge  slowly  and 
der  from  mixed  infection.  Often  progressively.  Mixed  infection  is  un- 
very  large.     Begin  to  subside  in  a  common. 

few  weeks. 

4.  Course. — The  sores  and  nodes  4.  Advance  slow  and  progressive 
reach  their  height  in  a  few  weeks,  and      for  months. 

as  they  subside  the  secondary  lesions 

appear.  5.  Secretion  contains  vulgar  spirilla. 

5.  Secretion  contains  spirochetae.  Biopsy  shows  epithelial  pearls. 

Chancre  within  the  Mouth. — Chancre  within  the  mouth 
has  been  erroneously  diagnosed  as  often,  probably,  as  any  other 
lesion  of  syphilis.  This  because  of  the  prevalence  of  Vincent's 
angina,  a  fairly  common  infection,  absolutely  unknown  to  the 
general  practitioner,  and  which  causes  lesions  quite  indistin- 
guishable by  the  ordinary  clinical  tests  from  chancre. 

Vincent's  angina  is  an  acute  infection  of  the  mouth  caused 
by  a  long  spirillum  and  a  short,  thick  bacterium,  pointed  at 
the  ends.  It  is  characterized  by  a  generalized  inflammation 
of  the  mucous  membrane,  or  by  ulceration,  or  both.  It  is 
very  obstinate  to  treatment,  though  ultimately  curable  by  cau- 
terization, preferably  with  nitrate  of  silver. 

Four  out  of  the  six  last  cases  of  "  chancre  "  of  the  m,outh 
that  I  have  seen  were  Vincent's  angina,   I   believe.      I   can 


250  DIAGNOSIS    OF    THE    INITIAL    LESION 

in  no  wise  better  express  my  sense  of  the  importance  of  the 
condition  than  by  briefly  reciting  these  cases : 

Case  XXVIII. — Eighteen  months  ago  a  gentleman  consulted 
me  about  an  ulceration  on  the  tip  of  his  tongue.  It  had  been 
there  three  months  in  spite  of  various  local  treatments  applied 
by  sundry  physicians  in  the  various  capitals  of  Europe.  Some 
had  said  it  was  syphilis ;  others,  not. 

There  were  no  enlarged  nodes.  The  ulcer  itself  was  so  irri- 
tated by  recent  frequent  cauterization  that  its  character  was  that 
of  a  severe  burn — a  ragged  ulcer  with  raised,  thick  edges,  on 
the  tip  of  the  tongue.     It  was  very  painful. 

The  duration,  the  absence  of  enlarged  nodes  and  of  any 
secondaries,  assured  me  that  the  condition  was  not  syphilitic. 
He  promptly  recovered  under  local  applications  at  the  hands  of 
another  physician.     He  has  had  no  further  S3'mptoms. 

Case  XXIX. — About  six  months  later,  a  handsome  young 
fellow,  about  to  be  married,  consulted  me  concerning  a  sore  on 
his  left  tonsil.  An  eminent  laryngologist  had  just  told  him  it 
was  chancre.  He  vowed  he  had  kissed  no  one  except  his  be- 
trothed for  three  months. 

Yet  the  sore  was  a  typical  chancre.  It  had  existed  a  week, 
covered  the  whole  tonsil  with  a  dark  red  induration,  upon  which 
was  a  slight  ulceration  recently  cauterized  by  the  laryngologist. 
The  nodes  under  the  angle  of  the  jaw  were  large  and  tender, 
the  sore  itself  exquisitely  sensitive. 

The  poor  lad  was  in  despair  when  I  told  him  his  wedding 
must  be  postponed,  and  my  unwillingness  to  make  a  diagnosis 
on  the  chancre  alone  was  small  consolation  to  him.  But  he 
returned  to  the  specialist  for  local  applications,  under  which  the 
sore  healed  in  six  weeks.  He  has  not  yet  developed  any  further 
symptoms  of  syphilis. 

Case  XXX. — As  yet  I  knew  nothing  of  Vincent  and  his 
angina.  But  in  the  spring  of  1906  I  was  summoned  to  examine 
the  throats  of  a  young  man  and  his  wife.  He  showed  on  his 
left  tonsil  a  superficial  ulcer  covered  with  false  membrane  and 
set  in  a  slightly  indurated  border.  Surrounding  it  was  an  area 
of  inflammation  extending  forward  toward  the  lower  jaw.  In- 
deed, the  patient  insisted  that  the  sore  had  begun  on  the  lower 
jaw  and  had  moved  back  to  the  tonsil ;  but  the  absence  of  scar 


DIAGNOSIS    OF    CHANCRE    OF   THE    MOUTH  251 

discredited  this  story.  The  nodes  under  the  jaw  were  enlarged, 
and  both  sore  and  nodes  were  exquisitely  tender. 

The  wife  showed  a  similar  lesion  on  the  right  side  of  the 
mouth  at  the  angle  of  the  jaws.     It  was  a  week  old. 

I  made  the  diagnosis  of  syphilis  in  the  belief  that  two  prob- 
abilities make  a  certainty,  and  for  proof  had  a  smear  examined. 
The  smear  was  returned  with  a  diagnosis  of  Vincent's  angina. 
Neither  developed  syphilis. 

These  cases  sum  up  the  differentiating  points,^  which  are: 

1.  The  tenderness  is  much  more  marked  in  Vincent's  an- 
gina than  in  chancre. 

2.  The  anginous  sore  (unless  cauterized)  is  more  super- 
ficial than  chancre,  and  is  likely  to  be  surrounded  by  more  or 
less  general  inflammation. 

3.  The  glands  may  be  large  and  tender  in  either  case. 

4.  Chancre  gets  well  spontaneously;  the  angina  may  or 
may  not. 

5.  ]\Iicroscopic  examination  of  a  smear  establishes  the 
diagnosis. 

Chancre  of  the  Tongue. — This  must  be  dift'erentiated  from 
traumatic  ulcer,  due  to  a  ragged  tooth,  from  tubercle,  from 
gumma,  from  neoplasm,  and  from  Vincent's  angina  (see 
above). 

Inspection  of  the  teeth  reveals  the  cause  of  traumatic  ulcer- 
ation. 

The  chief  points  to  distinguish  chancre  from  neoplasm  are 
those  already  detailed  for  chancre  of  the  lip. 

Gumma,  apart  from  other  evidences  of  syphilis,  is  distin- 
guished by  its  slowdy  progressive  course  and  the  late  involve- 
ment of  the  glands. 

Tuberculosis  is  rare.  The  ulceration  is  irregular,  ragged, 
eaten,   and    exquisitely   sensitive,    ^vhi1e    chancre    is    rounded, 

1  ]\Ialherbe  {Gaz.  med.  de  Nantes,  1905,  vol.  xxiii,  p.  977)  reports  a  case  of 
buccal  chancre  complicated  by  Vincent's  angina. 


252 


DIAGNOSIS    OF    THE    INITIAL    LESION 


smooth,  superficial,  insensitive.  Moreover,  tubercular  ulcera- 
tions may  be  multiple,  upon  the  under  surface  of  the  tongue 
(where  chancre  has  not  been  seen),  and  accompanied  by  other 
tubercular'  lesions. 

The  secondary  explosion  and  the  examination  of  a  section 
from  the  growth  form  the  final  tests. 


CHAPTER    XVIII 

SYPHILITIC   TOXEMIA 

In  displaying  the  many-sided  image  of  syphilitic  toxemia, 
we  must  remember  the  late  toxemia  of  chronic  syphilis  as  well 
as  acute,  early  syphilitic  toxemia. 

Accordingly,  the  subject  may  be  divided  under  two  main 
heads,  as  follows : 

Acute  Syphilitic  Toxemia: 

Hematology  and  pathological  anatomy. 
The  fever  of  early  syphilis. 
General  debility. 
Symptoms  of  local  congestion. 
Chronic  Syphilitic  Toxemia: 
The  fever  of  late  syphilis. 
Arterial  and  visceral  sclerosis. 
Amyloid  disease  of  the  viscera. 

ACUTE    SYPHILITIC    TOXEMIA 

Apart  from  the  primary  lesion  the  symptoms  of  the  first 
few  months  of  syphilis  resemble  those  of  the  acute  exanthem- 
ata. There  are  (i)  changes  in  the  blood,  (2)  certain  visceral 
congestions,   (3)   fever,  and  (4)  the  exanthem  itself. 

As  we  see  the  disease  in  the  United  States  at  the  present 
day,  the  early  local  lesions  of  skin  and  mucous  membranes 
so  overshadow  the  mild  evidences  of  general  intoxication  that 
we  almost  forget  they  exist  until  reminded  by  the  occasional 
case  of  grave  debility  or  severe  fever.     Under  other  condi- 

253 


254  SYPHILITIC   TOXEMIA 

tions,  however,  grave  toxemia  is  much  more  common.  Thus 
Fournier,  for  instance,  states  that  while  this  condition  is  un- 
common in  his  private  practice,  he  has  found  syphiHtic  fever 
(only  one  of  the  manifestations  of  toxemia)  in  one  third  of 
the  women  who  visit  his  clinics. 

Indeed,  the  toxemia  of  syphilis  is  much  more  frequently 
observed  in  women  than  in  men.  Yet  a  mild  toxemia,  a  tox- 
emia readily  overlooked  by  the  physician,  may  be  noted  in  the 
great  majority  of  syphilitics.  This  toxemia  shows  itself,  not 
by  any  striking  symptoms  of  pain  or  fever,  but  by  a  definite 
reduction  of  the  vital  forces  and  a  marked  loss  of  weight  per- 
sisting during  the  first  six  to  twelve  months  after  the  onset  of 
the  secondary  symptoms. 

HEMATOLOGY 

The  pathology  of  the  blood  in  syphilis  varies  widely,  and 
generally  in  direct  proportion  to  the  severity  of  the  lesions. 
Grave  lesions,  whether  secondary  or  tertiary,  are  associated 
with  marked  anemia,  while  patients  who  suffer  little  from 
the  disease  show  no  marked  blood  changes  at  any  time. 
Women,  inasmuch  as  they  suffer  more  severely  than  men  from 
the  toxemia  of  syphilis,  usually  show  a  more  intense  anemia, 
which  is  likely  to  be  of  the  chlorotic  type. 

Syphilis  scorns  law,  and,  accordingly,  we  find  it  assum- 
ing almost  every  form  of  blood  change,  simulating  simple 
anemia,  chloroanemia,  leukemia,  and  pernicious  anemia ; 
while  leukocytosis  occurs  and  disappears  with  no  absolute  rule. 
The  usual  changes  in  the  blood  found  in  early  syphilis,  how- 
ever, are  the  following: 

The  Red  Cells. — Before  the  outbreak  of  secondary  symp- 
touis,  the  first  sign  of  systemic  infection  is  a  fall  in  the  hemo- 
globin. This  loss  may  amount  to  fifteen  per  cent  or  thirty  per 
cent  before  the  eruption  appears.     Meanwhile  there  is  little  or 


HEMATOLOGY  255 

no  change  in  the  red  cell  count.  Thus  the  preliminary  condi- 
tion is  a  syphilitic  chloroanemia. 

With  the  secondary  outbreak  of  local  symptoms  or  of 
fever,  and  to  a  less  degree  with  each  subsequent  outbreak, 
there  is  a  rapid  fall  in  the  number  of  red  blood  cells,  while 
the  fall  in  hemoglobin  continues.  The  cells  usually  fall  to 
between  3,500,000  and  4,500,000,  the  hemoglobin  to  sixty 
or  seventy  per  cent.  The  two  go  hand  in  hand,  and  thus  con- 
stitute a  simple  anemia,  though  the  preliminary  chloroanemia, 
with  relative  hemoglobin  deficiency,  may  persist. 

Administration  of  mercury  rapidly  renews  the  red  cells, 
though  the  return  of  hemoglobin  to  normal  may  be  somewhat 
slower,  so  that  the  patient  may  pass  through  another  stage  of 
chloroanemia  on  the  way  to  recovery. 

All  foreign  authors  are  agreed  that  prolonged  administra- 
tion of  mercury  has  a  poisonous  effect,  causes  a  rediminution 
of  cells  and  loss  of  hemoglobin.  This  toxic  effect  they  look 
for  in  three  to  five  weeks.  Hence  the  interrupted  method  of 
treatment  (page  153).  We  in  America,  however,  continue 
to  get  good  results  from  continued  treatment,  and  find  that  it 
does  not  impoverish  the  blood.  An  example  is  given  below 
of  an  excellent  blood  condition  after  nine  months  of  continu- 
ous and  effective  treatment  by  mercury,  partly  by  injections 
of  salicylate,  partly  by  protiodid  granules.  Indeed,  thirty 
years  ago  my  father  showed  that,  under  proper  dosage, 
this  excellent  condition  would  persist  for  five  years  ^ — long 
enough  for  all  practical  purposes. 

The_White  Cells. — Before  the  secondary  eruption  the 
leukocytes  are  normal  or  increased  in  number,  but  there  is  no 
marked  change  until — 

With  the  secondary  outbreak  there  is  usually,  though  not 
necessarily,  a  distinct  leukocytosis — 10,000  to  15,000,  or  even 


1  Am.  J.  Med.  Sci.,  1876,  January. 


256  SYPHILITIC    TOXEMIA 

higher.  Differential  count  shows  increased  lymphocytes  and 
marked  falling  off  of  the  polymorphonuclear  neutrophiles. 
An  increase  in  the  eosinophiles  and  mononuclears  -^  is  so  often 
seen  that  it  was  at  one  time  deemed  part  of  the  morbid  proc- 
ess; but  further  investigation  has  proven  it  by  no  means 
constant. 

The  effect  of  mercury  is  to  dissipate  leukocytosis  (if  this 
exists)  and  to  bring  back  to  normal  the  disturbed  relation 
between  lymphocytes  and  polymorphonuclears.  This  is  quite 
the  opposite  to  the  effect  of  mercury  upon  non-syphilitic  blood, 
which  is  to  increase  the  lymphocytes. 

The  following  example  is  typical.  The  first  column  of 
figures  shows  the  condition  a  month  after  the  secondary  out- 
break and  at  the  time  treatment  was  begun.  The  second  col- 
umn shows  the  conditions  after  nine  months  of  continuous 
treatment.  (The  patient  is  now  in  the'  third  3'ear  of  his 
disease,  and  has  had  no  relapse  since  the  initial  outbreak.) 
The  tonic  effect  of  mercury  is  well  shown. 

Hemoglobin 75  per  cent.     98  per  cent. 

Red  blood  cells 4,084,000         5,440,000 

Leukocytes 15,600  8,200 

Poikilocytosis  and  slight  variations  in  the  size  of  the  red 
cells  were  noted  in  the  first  specimen,  not  in  the  second.  No 
degenerated  or  nucleated  red  cells,  no  pigmented  leukocytes 
or  malarial  plasmodia  in  either. 

The  differential  count  showed : 

Per  cent.       Per  cent. 

Polynuclear  neutrophiles 57  73 

Small  lymphocytes 32  16 

Large  lymphocytes 4  5 

Mononuclears i  i 

Transitionals 2  i 

Eosinophiles 3.5  2 

Basophiles 0.5  2 


Hanck,  Archiv  jiir  Derm.  u.  Syph.,  1905,  vol.  Ixxviii,  pp.  45,  289. 


THE    FEVER    OF    EARLY    SYPHILIS  257 

Course. — The  secondary  anemia  of  syphilis  begins  before 
the  outbreak  of  secondary  symptoms  and  grows  more  intense 
up  to  this  outbreak.  Then,  as  the  eruption  subsides,  the 
anemia  decreases  only  to  relapse  with  each  recurrence  of  local 
syphilitic  lesions. 

Thus  a  mild  case  may  show  but  insignificant  blood  changes, 
which  soon  disappear,  even  without  treatment,  while  the 
gravest  cases  continue  anemic  for  months  in  spite  of  all  one 
can  do.  The  average  syphilitic  ceases  to  be  anemic  after  the 
first  year  of  the  disease,  this  cessation  being  due  both  to  time 
and  to  treatment. 

AVhen  the  anemia  persists  in  spite  of  intelligent  adminis- 
tration of  mercury,  it  must  be  attacked  by  hygiene,  aided  by 
iron,  arsenic,  and  cod-liver  oil. 

PATHOLOGICAL   ANATOMY 

The  generalized  congestive  and  exudative  processes  that 
result  from  manifold  deposits  of  spirochetje  in  the  capillary 
walls  produce  upon  the  skin  the  familiar,  early,  macular, 
papular,  and  tubercular  general  syphilids.  Similar  deposits 
doubtless  occur  throughout  the  body.  The  resulting  areas  of 
congestion  or  exudation,  if  minute  and  scattered,  evoke  no 
symptoms  and  pass  unrecognized.  But  if  more  pronounced 
in  certain  organs  they  evoke  the  symptoms  enumerated  below. 

THE    FEVER    OF   EARLY   SYPHILIS 

The  fever  of  early  syphilis  is  usually  dependent  upon  the 
general  infection,  exceptionally  upon  the  local  lesions.  Hence 
there  are  two  types,  the  essential  and  the  eruptive. 

In  private  practice  syphilitic  fever  is  most  exceptional. 
Fournierfrom  his  clinical  experience  states  that  young  anemic 
prostitutes    very    commonly    (every   third    case)    show    some 


258  SYPHILITIC   TOXEMIA 

fever  during  the  first  six  months  of  the  disease,  but  recognizes 
its  rarity  in  men  and  in  the  better  classes  of  women. 

Though  it  is  quite  possible  for  a  patient  to  run  a  slight 
temperature  for  several  days  without  noting  it,  any  fever 
severe  enough  to  arouse  complaint  it  has  not  been  my  fortune 
to  note,  except  only  the  prodromal  essential  fever. 

The  Essential  Type. — As  I  have  seen  it,  the  fever  of  large 
pox  (syphilis),  like  that  of  small-pox,  precedes  the  eruption. 

This  fever  occurs  during  the  two  weeks  immediately  pre- 
ceding the  eruption.^  It  is  usually  mild,  lasts  from  three  to 
ten  days,  and  is  accompanied  by  the  pains  and  malaise  asso- 
ciated in  the  public  mind  with  influenza.  The  temperature 
rarely  goes  aboye  102°  F.,  with  a  drop  of  a  degree  or  so  each 
morning. 

The  fever  is  commonly  mistaken  for  typhoid  or  influenza 
until  the  appearance  of  the  rash.  Immediately  the  fever  drops 
to  normal,  and  the  diagnosis  is  clear  (though  once  I  have 
known  it  to  be  mistaken  for  measles).  This  preeruptive  drop 
may  be  rapid  or  gradual. 

The  essential  fever  recognized  by  Fournier  in  ill-nourished 
j^oung  women  occurs  in  the  first  six  months  of  syphilis,  and 
generally  follows  the  type  described  above.  Less  commonly, 
it  imitates  (i)  malaria,  (2)  typhoid,  or  is  (3)  utterly  irregu- 
lar. The  malarial  type  is  quotidian,  occurs  late  in  the  day, 
and  is  not  a  complete  paroxysm  of  chill,  fever,  sweat,  but  rather 
irregular  and  abortive.  The  typhoidal  type  is  more  confusing, 
but  history  and  Widal  test  should  make  the  diagnosis. 

Bulimia  (increase  of  appetite)  sometimes  accompanies  the 
fever.  This  symptom  may  suffice  to  suggest  syphilis,  for  in 
no  other  fever  is  it  so  marked.  The  patient  with  a  tempera- 
ture of  101°  and  a  voracious  appetite  is  a  living  paradox. 

*  In  several  patients  whose  fever  was  severe  the  eruption  was  quite  late  in 
appearing,  as  though  the  fever  assumed  the  chronological  position  of  the 
eruption  and  so  postponed  it. 


GENERAL    DEBILITY  259 


GENERAL    DEBILITY 


Prodromes. — During  the  two  weeks  immediately  preced- 
ing the  general  eruption,  the  patient  shows  more  or  less  marked 
symptoms  of  systemic  intoxication. 

His  appearance  is  that  of  distress  and  depression.  He  is 
paler  than  is  w^arranted  by  the  loss  of  hemoglobin;  he  begins 
to  lose  weight;  he  eats  little  and  sleeps  badly  (though  excep- 
tionally there  is  bulimia,  as  noted  above)  ;  his  physical  and 
mental  strength  seems  to  desert  him ;  he  is  feeble  and  listless ; 
he  wears  a  cowed,  distressed  expression;  his  head  feels  full 
and  sore  or  aches  distinctly;  his  bones  may  be  painful  and 
tender. 

All  these  miseries  increase  tow^ard  nightfall.  If  there  is 
fever  this  intensifies  them;  if  the  patient  is  neurotic,  and  sus- 
pects the  nature  of  his  malady,  an  admixture  of  subjective 
woes  confuses  the  picture.  Moreover,  the  local  lesions  of 
brain,  bones,  joints,  liver,  etc.  (described  below),  may  add 
their  traits. 

Finger  has  observed  a  prodromal  accentuation  of  the  cuta- 
neous and  tendon  reflexes,  while  Bulkley  has  recorded  various 
changes  in  cutaneous  sensibility — paresthesia,  anesthesia,  anal- 
gesia— occurring  at  the  onset  of  secondary  syphilis  in  women; 
one  cannot  but  suspect  in  such  cases  a  latent  hysterical  tend- 
ency awakened  by  the  fear  as  much  as  by  the  toxemia  of 
syphilis. 

Under  Treatment. — After  the  outbreak  of  the  secondary 
eruptions,  these  symptoms  disappear,  not  immediately  like  the 
fever,  but  gradually  and  under  the  influence  of  treatment. 
The  more  acute  pains  and  aches  are  gone  in  a  few  weeks,  but 
the  depression  of  strength  and  spirits  lasts  longer  and  the  loss 
of  weight  continues  longest  of  all. 

After  the  first  few  months  all  may  be  well ;  the  patient. 

cleared  of  his  eruption  and   freed   of  his  toxemia,   is,  to   all 
19 


26o  SYPHILITIC    TOXEMIA 

appearances,  as  strong  and  clean  as  ever  he  was.  But  some 
patients  do  not  escape  so  soon.  They  require  six  months  or 
a  year  to  regain  their  weight  and  strength. 

Exceptional  cases  remain  under  weight  for  years,  even  per- 
manently (Case  III,  page  19).  Such  permanent  debility 
occurs  almost  exclusively  in  women. 

Nervous  Symptoms. — Say  to  yourself  calmly,  "  I  have 
syphilis,"  and  you  will  realize  in  some  faint  measure  the  hor- 
ror that  strikes  a  man  ignorant  of  all  save  the  wildest  and 
most  frightful  romances  concerning  the  disease,  when  you 
say  to  him,  "  You  have  syphilis." 

In  our  neurotic  age  one  is,  therefore,  astonished  rather  at 
the  rarity  than  at  the  frequency  of  neurotic  manifestations  in 
early  syphilis.  But  man  becomes  accustomed  to  anything; 
and  the  few  weeks  that  intervene  between  the  primary  and 
the  secondary  outbreak  are  usually  enough  to  calm  the  pa- 
tient's worst  fears.  The  impressions  that  persist  in  most 
cases  concern  the  falling  out  of  hair  and  the  falling  in  of 
nose. 

Indeed,  if  it  has  been  impossible  to  make  an  accurate  diag- 
nosis from  the  initial  lesion,  the  advent  of  secondary  symp- 
toms is  usually  hailed  with  something  like  joy;  for  the  cer- 
tainty of  an  evil  fate  is  infinitely  less  distressing  than  blank 
doubt.  Hence  the  horrors  of  syphilophobia  when  the  patient 
has  not  syphilis. 

Thus  it  is  not  remarkable  to  find  that  syphilis  excites  old 
neurasthenic  and  hysterical  taints,  or  even  develops  them  in 
persons  in  whom  they  had  never  shown  before — all  this  in  the 
first  months  of  the  disease,  as  a  rule. 

More  definite  nervous  symptoms,  such  as  neuralgia  and 
neuritis,  need  not  concern  us  here. 

In  what  proportion  certain  symptoms,  such  as  asthenia, 
cardiac  palpitations,  arrhythmia,  tachycardia,  dyspnea,  vomit- 
ing, gastralgia,  hyperidrosis,  cold  feet,  insomnia,  paresthesia, 


SYMPTOMS    OF    LOCAL    CONGESTION  261 

analgesia,  and  even  epilepsy  or  general  asthenia,  are  due  to 
toxemia  and  to  neurosis  must  be  decided  for  each  individual 
case. 

Fournier  gives  the  following  characteristics  of  the  anal- 
gesias of  secondary  syphilis :  They  are  ( i )  much  more  fre- 
quent than  anesthesia,  (2)  superficial — the  deeper  tissues 
retain  their  sensitiveness,  (3)  irregularly  distributed,  (4)  usu- 
ally found  in  the  mammary  region  and  on  the  back  of  the 
hand. 

SYMPTOMS  OF  LOCAL  CONGESTION 

Under  this  heading  it  were  proper  to  discuss  almost  every 
lesion  of  secondary  syphilis.  Such  is  not  my  purpose;  but 
there  are  certain  forms  of  visceral  and  bone  congestion  that 
occur  in  a  characteristic  manner  during  the  first  few  months 
of  syphilis;  these  it  is  convenient  to  group  together,  inasmuch 
as  they  form  part  of  the  secondary  outbreak,  and  are  due 
either  to  the  wide  distribution  of  spirochetae  throughout  the 
body  or  to  the  poisons  elaborated  by  them. 

These  lesions  are  in  order  of  importance : 

1.  Lesions  of  skin  and  mucous  membranes. 

2.  Lesions  of  the  lymph  nodes. 

3.  Lesions  of  the  bones,  joints,  and  muscles. 

4.  Lesions  of  the  brain  and  its  envelopes. 

5.  Lesions  of  the  abdominal  viscera. 

6.  Alopecia. 

Lesions  of  the  Skin  and  Mucous  Membranes. — These  con- 
stitute the  body  of  the  secondary  outbreak.  They  are  too 
important  for  brief  consideration  here. 

Lesions  of  the  Lymph  Nodes. — Though  the  adenitis  which 
forms  part  of  the  initial  lesion  is  apparently  limited  to  the 
adjacent  lymph  nodes  and  attacks  viciously  but  one  of  these, 
a  less  active  reaction  occurs  in  the  whole  chain  of  nodes  beyond. 
Thus  with  chancre  of  the  mouth  a  slight  enlargement  of  the 


262  SYPHILITIC    TOXEMIA 

anterior  chain  of  nodes  down  to  the  clavicle  may  sometimes  be 
noted. 

Generally  speaking,  however,  there  is  a  pause  between  the 
primary  and  the  secondary  adenitis.  A  single  group  of  nodes 
enlarges  with  the  chancre;  after  that  nothing  until  the  sec- 
ondary outbreak.  Then  a  general  adenitis  occurs;  not  the 
general  adenitis  one  would  expect  affecting  all  the  nodes ;  ^ 
but  an  adenitis  coniined  especially  to  certain  groups — notably 
to  the  posterior  cervical  and  epitrochlear. 

The  appearance  of  this  adenitis  may  immediately  precede 
or  immediately  follow  the  outbreak  of  skin  lesions.  Hence  it 
is  scarcely  possible  that  the  adenitis  is  secondary  to  lesions  of 
the  skin,  as  Sigmund  and  others  have  held,  or  to  lesions  of  the 
deeper  structures,  as  suggested  by  Lang.  Probably  it  is  simply 
due  to  diffusion  of  the  spirochetje  through  the  body.  Why 
the  posterior  cervical  and  epitrochlear  glands  should  be  most 
commonly  affected  we  do  not  know. 

The  characteristics  of  the  adenitis  are  those  of  the  primary 
adenitis  repeated.  The  nodes  form  hard,  elastic  swellings  in 
single  glands  or  in  a  little  group,  with  no  pain,  tenderness, 
or  periadenitis. 

Pathologically  there  is  congestion  of  the  parenchyma,  en- 
largement of  its  cells,  exudation  of  small  round  cells ;  later 
fatty  degeneration  and  atrophy.  When  actively  inflamed  the 
nodes  contain  a  few  spirochetse. 

The  epitrochlear  nodes  may  be  felt  as  small,  hard,  movable 
kernels,  one  or  two  in  number,  in  the  groove  in  front  of  the 
internal  epicondylar  ridge  of  the  humerus  and  behind  the  inner 
edge  of  the  biceps.  They  usually  lie  at  least  an  inch  above  the 
condyle,  sometimes  much  higher.  Slight  enlargements  can 
only  be  palpated  with  the  elbow  well  flexed.  The  inexpert  may 
confuse -the  brachial  artery  with  a  node. 

1  Though  such  generalized  syphilitic    adenopathy  does  occur  very  ex- 
ceptionally. 


SYMPTOMS    OF    LOCAL    CONGESTION  263 

The  posterior  cervical  nodes  most  commonly  enlarged  are 
those  running  along  the  edge  of  the  trapezius,  low  down,  two 
little  nodes  lying  high  up  on  the  nucha,  just  over  the  occipital 
bone,  and  a  node  lying  over  the  mastoid  process  of  the  tem- 
poral bone. 

Other  nodes  may  become  enlarged,  but  this  is  not  charac- 
teristic. 

Inasmuch  as  this  early  syphilitic  adenitis  forms  an  impor- 
tant element  in  the  diagnosis  of  syphilis,  its  occurrence  must 
be  carefully  noted.  Not  all  cases  of  early  syphilis  have  pal- 
pably enlarged  nodes.  Estimates  as  to  their  frequency  vary 
from  seventy-five  per  cent  to  ninety-nine  per  cent :  I  should 
accept  the  lowest  estimate.  Hence  if  the  nodes  are  enlarged  it 
is  very  suggestive,  almost  convincing;  ^  but  if  they  are  not 
enlarged,  the  evidence  has_no„Yalue.  v 

The  secondary  adenitis   lasts  usually   from  one  to   three 

•  months,  very  rarely  into  the  second  or  third  year.     Hence  jt 

is  absurd  to  depend  upon  it  for  a  diagnostic  aid  after  the  first 

few  months  of  the  disease.     To  "  diagnose  syphilis  from  the 

I  state  of  the  nodes"  is  a  perilous  venture. 

'       Lesions  of  the  Bones,  Joints,  and  Muscles. — The  pains  of 

early  syphilis,  so  much  feared  by  those  who  know  little  about 

the  disease,  occurred  in  twenty-one  per  cent  of  the  men  among 

my  cases  and  in  thirty-three  per  cent  of  the  women    (page 

86).     Mild  pains,  of  which  the  patient  did  not  complain,  are 

not  included  in  this  estimate. 

These  pains  have  been  called  osteocopic  (bone-breaking) 
because  of  their  severity  and  their  predilection  for  the  osseous 
system.  They  precede  or  accompany  the  secondary  outbreak. 
Whether  continuous  or  intermittent,  they  are  typically  noctur- 

1  The  posterior  cervical  and  epitrochlear  nodes  may,  like  any  others,  be 
enlarged  from  local  absorption.  But  when  the  two  sets  are  enlarged  simul- 
taneously and  are  rather  hard  and  entirely  insensitive,  syphilis  may  almost  be 
diagnosed  from  this  fact  alone. 


264  SYPHILITIC    TOXEMIA 

nal,  i.  e.,  they  increase  markedly  at  about  sundown,  and  do  not 
let  up  till  morning.  They  may  last  for  several  weeks  if  un- 
treated, but  under  light  doses  of  potassium  iodid  they  promptly 
disappear. 

These  pains  may  be  vague  and  diffuse,  but  are  more  often 
definitely  localized  in  a  given  bone,  joint,  or  muscle.  Palpa- 
tion usually  reveals  some  point  of  sensitiveness. 

Manifestly,  therefore,  these  pains  are  due  to  localised 
syphilitic  manifestations,  and  may  be  put  down  to  acute  perios- 
titis, myositis,  or  arthritis,  as  the  case  may  be.  Indeed,  in 
severe  or  neglected  cases,  the  condition  readily  passes  from 
mere  pain  to  manifest  syphilitic  inflammation  of  bone,  joint, 
or  muscle. 

A  description  of  such  characteristic  types  as  pleurodynia, 
myosalgia,  and  arthralgia  may  suffice  to  elucidate  the  subject. 
Headache  is  described  below. 

Pleurodynia  is  a  sharp  pain  in  the  side,  precisely  similar 
in  character  and  intensity  to  that  of  acute  pleurisy,  but  occur- 
ring essentially  at  night.  By  day  it  is  absent  or  slight,  but 
throughout  the  night  it  rages.  A  tender  point  may  be  found 
on  one  or  more  of  the  ribs  or  cartilages. 

Myosalgia  may  cause  torticollis  or  lumbago.  It  often 
affects  the  legs.  It  is  a  typical  nocturnal  pain,  but  is  excited 
by  movement  of  the  affected  muscle,  and,  consequently,  it  ex- 
cites instinctive  rigidity.  The  muscle  may  or  may  not  be  sen- 
sitive to  pressure. 

Arthralgia  is  pain  in  a  joint  unaccompanied  by  effusion. 
It  occurs  chiefly  at  night,  and  is  improved  by  exercise  (during 
the  day).  Knee,  shoulder,  elbow,  wrist,  and  ankle  are  the 
joints  most  often  involved. 

Lesions  of  the  Brain  and  Its  Envelopes. — Headache  is  the 
most  frequent  as  well  as  the  most  important  form  of  pain  at 
the  onset  of  syphilis.  It  may  be  slight  or  severe,  throbbing, 
constricting,  or  weighing.     It  is  felt  chiefly  in  the  frontal  or 


SYMPTOMS    OF    LOCAL   CONGESTION  265 

occipital  regions.  Like  all  the  pains  of  sypJiilis  it  is  much 
intensified  at  night. 

The  exact  lesion  may  be  difficult  to  trace.  Lang  con- 
cludes that  many  headaches  are  due  to  meningeal  irritation, 
since  the  ophthalmoscope  often  shows  retinal  congestion 
(though  sight  is  not  impaired).  In  other  cases  tenderness  over 
some  portion  of  the  skull  suggests  a  periosteal  lesion. 

But  the  great  importance  of  early  syphilitic  headache  lies 
in  the  fact  that  zve  can  never  tell  zvhether  or  not  it  is  a  warn- 
ing of  some  grave  intracranial  lesion.  The  severest  headache 
may  lead  to  nothing,  yet  a  mild  pain  may  be  the  first  sign  of  a 
hemiplegia  or  meningitis.  Ricord  has  said :  "  Suspect  every 
rebellious  headache  of  being  syphilitic  " ;  let  us  add :  Attack 
every  syphilitic  headache  with  vigor  and  determination.  At- 
tack it  as  though  you  knew  it  portended  cerebral  syphilis ;  thus 
you  will  abort  many  a  grave  lesion. 

Lesions  of  the  Abdominal  Viscera. — Jaundice,  though 
very  rare,  is  the  most  important  lesion  under  this  head.  The 
symptoms  are  those  of  ordinary  catarrhal  jaundice.  The  liver 
is  enlarged  and  slightly  sensitive.  Bile  is  absent  from  the 
stools,  present  in  the  urine  and  the  skin.  The  cause  is  not 
known.  It  has  been  attributed  to  pressure  of  enlarged  glands 
on  the  ducts,  to  hepatitis,  even  to  "  roseola "  of  the  'ducts. 
Suffice  it  to  say  that  it  usually  disappears  in  two  or  three 
weeks. 

Enlargement  of  the  spleen  was  noted  by  Woelfert  in  16  out 
of  490  cases  of  early  syphilis.  It  has  no  clinical  significance 
and  subsides  spontaneously. 

The  digestive  and  renal  lesions  of  syphilis  do  not  usually 
form  part  of  the  secondary  explosion. 

Alopecia. — Alopecia  is  one  of  the  latest,  the  least  impor- 
tant, and  the  most  feared  lesions  of  the  secondary  outbreak. 
It  occurs  between  the  third  and  the  eighth  month  of  the  dis- 
ease. 


266 


SYPHILITIC    TOXEMIA 


Alopecia  in  syphilis  may  be  essential  or  syniptomatic.    The 

latter,  falling  of  the  hair  over  ulcerative  lesions  on  account  of 

destruction  of  the  papillae,  has  no  peculiar  features  and  requires 

no  comment. 

The  essential  alopecia  affects  the  hair  of  the  scalp  almost 

exclusively.     Three  degrees  may  be  distinguished. 

I.   General  thinning  of  the  hair  occurs  to  some  degree  in 

almost  every  case  of  syphilis.     The  hair  falls  freely  for  a  few 

months,  and  then  re- 
turns to  its  original 
thickness.  But,  as 
in  the  other  exan- 
themata, the  texture 
of  the  hair  may  be 
permanently  altered. 
Moreover,  since 
syphilis  is  usually 
acquired  at  the  age 
when  senile  baldness 
begins,  the  hair  of 
the  crown  or  over 
the  temples  may 
never  return ;  but 
this  is  no  fault  of 
the  disease. 

2.  Besides   the 
Fig.  1 6. — Syphilitic  Alopecia.     (Pusey.)  general  thinning,  the 

hair  may   fall  more 

markedly  in  certain  parts  than  in  others.     This  produces  a 

characteristic,  mottled,  moth-eaten  appearance,  which  is  almost 

pathognomonic  (Fig.   i6). 

3.  Finally,  this  mottling  may  be  so  intense  as  to  produce 

spots  of  baldness  quite  similar  to  those  of  alopecia  areata,  but 

distinguishable  by  three  characteristics. 


CHRONIC    SYPHILITIC    TOXEMIA  267 

Syphilitic  alopecia  Alopecia  areata 

Spots  irregular  in  shape.  Spots  absolutely  rounded  in 

contour. 

Spots  not   absolutely   bald,    a     Spots  absolutely  bald, 
few  stray  hairs  are  spared. 

Skin  of  the  spots  normal.  Skin  glossy,  white,  and  atro- 

phic. 

The  two  more  intense  degrees  of  syphilitic  alopecia  are 
quite  rare.     I  have  seen  but  three  cases  of  the  third. 

Alopecia  areata  occurs  quite  frequently  in  syphilitics;  but 
it  is  generally  believed  that  there  is  no  essential  connection 
between  the  two  maladies. 

The  pathology  of  syphilitic  alopecia  is  obscure.  The  fall 
of  hair  seems  to  be  due  to  the  general  toxemia. 

Any  stimulating  lotion  suffices  for  treatment.  The  fol- 
lowing are  excellent : 

^   Tr.  capsici Sij-v  (8-20  c.c.)  ; 

Glycerin^e 5ss  (2  c.c.)  ; 

Aqua  colognensis ad  %\  (ad  30  c.c). 

or 

1^  Tr.  cantharidis "Hlxv  ( i  c.c.)  ; 

01.  ricini Tllij    (0.12  c.c.)  ; 

Aqua  colognensis ad  oi   (ad  30  c.c). 

or 

^  Resorcin gr.  xv  ( i  gm.)  ; 


Alcohol, 
Aquse, 


i aa  ad  .51   (aa  ad  30  c.c), 


CHRONIC    SYPHILITIC    TOXEMIA 

Chronic  syphilitic  toxemia  is  rare,  complex  in  cause,  and 
clinically  atypical.     Thus  it  differs  markedly  from  the  clean- 


268  SYPHILITIC    TOXEMIA 

cut  type  of  acute  syphilitic  toxemia  described  in  the  preceding 
paragraphs. 

It  is  rare,  so  rare  that  nine  out  of  ten  syphilitics  (in  the 
United  States)  may  be  said  to  escape  it  ahogether. 

It  is  complex  in  cause ;  indeed,  exckisive  of  the  "  fever  of 
late  syphilis,"  it  is  scarcely  ever  caused  by  syphilis  alone.  It 
is  due,  habitually,  to  some  combination  of  syphilis  with  alco- 
holism, neglect,  privation,  etc.,  amidst  which  it  may  be  impos- 
sible to  distinguish  essential  or  preponderant  cause. 

It  is  clinically  atypical,  for  its  type  varies  somewhat  with 
every  case.  For  example,  Case  III  (page  19)  is  an  instance 
of  chronic  debility  (doubtless  tubercular),  prolonged  for  years 
after  the  first  acute  toxemia.  The  fever  of  late  syphilis  (see 
below)  is  a  second  type.  As  a  third  instance  I  may  cite  the 
the  following: 

Case  XXXI. — A  stout,  middle-aged  man,  having  suffered  for 
years  from  ulcerative  paronychia  of  the  great  toe,  was  suddenly 
overwhelmed  last  winter  by  a  general  outbreak  of  an  ulcerative 
syphilid.  A  dozen  lesions  broke  out  upon  him  almost  simulta- 
neously, varying  in  diameter  from  2  to  6  cm.  He  could  not 
sleep  because  of  the  sores  on  his  trunk,  nor  walk  because  of 
those  on  his  foot.  He  had  a  slight  afternoon  temperature ;  he 
could  not  eat,  in  two  weeks  he  lost  twenty  pounds.  When  I 
first  saw  him  he  had  been  overtreated  with  iodids,  and  four  injec- 
tions of  gray  oil  sufficed  to  relieve  him.  Six  weeks  later  another 
acute  relapse  was  equally  readily  cured.  (He  has  remained  well 
one  year.) 

Case  VI  showed  a  similar  toxemia,  purely  syphilitic  in 
nature  until  superseded  by  the  iodid  toxemia. 

A  fourth  type  is  that  of  the  sufferer  from  arteriosclerosis 
or  visceral  sclerosis  (under  the  clinical  type  of  hepatic  cirrho- 
sis or  chronic  interstitial  nephritis)  ;  a  fifth,  that  of  amyloid 
disease  of  the  viscera. 

Of  these  five  more  or  less  empyric  types  of  chronic  toxemia, 


CHRONIC    SYPHILITIC    TOXEMIA  269 

t 

only  the  second  (syphilitic  fever)  and  the  two  last  require  any 
special  comment. 

The  Fever  of  Late  Syphilis. — The  fever  of  late  syphilis  is 
one  of  the  most  impenetrable  mysteries  of  the  disease.  When 
we  have  said  that  its  cause  is  unknown,  its  type  chronic  and 
irregular,  its  cure,  mixed  treatment,  we  have  summed  up 
almost  all  our  knowledge  on  the  subject. 

The  following  conclusions,  drawn  chiefly  from  a  resume  of 
Dr.  Arthur  Birt,^  summarize  the  consensus  of  opinion  upon 
this  subject : 

1.  Late  visceral  syphilis  is  attended  with  persistent  fever 
much  more  commonly  than  is  generally  recognized. 

2.  Though  variable  in  type  and  sometimes  accompanied 
by  chills  and  night-sweats  (simulating  tuberculosis)  or  by 
chills  and  fever  (simulating  malaria  or  sepsis),  it  is  usually 
a  prolonged,  low-grade  fever  which  may  last  quite  indefi- 
nitely. 

3.  Though  usually  accompanied  by  evidences  of  liver 
syphilis,  these  are  rarely  marked,  sometimes  absent  (Jane way, 
D'Amato),  and  sometimes  replaced  by  lung  syphilis  (Sobern- 
heim). 

4.  Moreover,  the  fever,  like  the  visceral  lesions,  always 
occurs  years  (sometimes  fifteen  or  twenty)  after  the  chancre. 

5.  Hence  its  nature  may  often  be  determined  only  by  ex- 
clusion and  by  the  "  test  course  "  of  mixed  treatment,  though 
a  careful  history  and  physical  examination  reveal  the  nature 
of  many  cases. 

6.  Every  atypical  fever  of  unknown  origin  should,  how- 
ever, be  considered  suspect. 

>  Montreal  Med.  J.,  1905,  vol.  xxxiv,  p.  748.  Other  recent  contributions  are 
those  of  D'Amato,  Rijorma  nied.,  1906,  vol.  xxii,  No.  9;  Mannaberg,  Zeitschr. 
fiir  klein  Med.,  1907,  vol.  xii;  Klemperer,  Zeitschr.,  jiir  klein  Med.,  1905,  vol.  iv; 
Sobemheim,  TJierap.  der  Gegenwart,  1905,  vol.  vii,  p.  486;  and  Raubitschek, 
Centralbl.  /.  d.  Grenzgeb.  der  Med.  u.  Chir.,  1907,  vol.  ix,  p.  641. 


27©  SYPHILITIC  TOXEMIA 

7.  Mild  mixed  treatment  suffices  for  a  cure  and  a  severe 
course  may  do  harm. 

Arterial  and  Visceral  Sclerosis. — That  syphilis  may  cause 
arteriosclerosis  and  interstitial  inflammations  of  the  viscera 
has  long  been  an  accepted  doctrine. .  That  it  often  does  cause 
them  is  extremely  doubtful.  Certainly  the  great  majority  of 
cases  are  not  syphilitic,  and  equally  certainly  those  patients 
who,  having  had  syphilis,  come  to  have  sclerotic  arteries  or 
chronic  interstitial  nephritis  or  hepatic  cirrhosis,  are  in  no  wise 
different  from  their  non-syphilitic  brethren.  One  may  be 
tempted  in  a  given  case  to  believe  that  a  prolonged,  neglected 
syphilis  must  "have  had  some  share  in  the  production  of  these 
lesions,  while  recognizing  that  such  a  theory  has  no  clinical 
or  therapeutic  bearing  upon  the  case  except  to  spur  one's  efforts 
toward  healing  the  syphilis  if  any  trace  of  it  persists. 

Amyloid  Degeneration  of  the  Viscera. — Almost  the  same 
may  be  said  of  amyloid  degeneration  of  the  viscera.  It  may 
be  caused  by  inveterate,  neglected  syphilis ;  ^  indeed,  it  may 
complicate  syphilitic  disease  of  the  viscera.  But  amyloid  de- 
generation of  syphilitic  origin  is  no  different  from  amyloid 
disease  of  other  provenance.  Antisyphilitic  treatment  can  only 
do  it  harm. 

1  It  is  much  more  commonly  due  to  tuberculosis  or  to  sepsis. 


CHAPTER    XIX 
SYPHILIS  OF  THE  SKIN:    GENERAL  CHARACTERISTICS 

Divers  and  dissimilar  as  are  the  skin  lesions  of  syphilis 
(the  syphilids,  as  they  are  more  concisely  termed),  they  have, 
nevertheless,  certain  general  characteristics  to  which  they  ad- 
here quite  faithfully  and  which  serve  as  diagnostic  criteria. 
Indeed,  a  thorough  familiarity  with  these  general  characteris- 
tics and  with  the  way  in  which  the  various  syphilids  conform 
to  them  is  of  more  service  in  diagnosis  than  any  knowledge  of 
individual  types  of  eruption. 

These  general  characteristics  are  clinical  and  pathological. 
The  general  clinical  characteristics  are  the  following: 

GENERAL   CLINICAL   CHARACTERISTICS 

1.  Slow  and  progressive  development. 

2.  Polymorphism. 

3.  Absence  of  local,  general  inflammatory  reaction. 

4.  Absence  of  pain  and  itching. 

5.  Peculiar  raw-ham  color. 

6.  Rounded  form. 

7.  Scales  white,  superficial,  non-adherent. 

8.  Crusts  greenish  or  black,  thick,  irregidar,  adherent. 

9.  Ulcerations  rounded  or  circinate,   with  abrupt  edges, 
sanious  secretion  and  sluggish  base. 

10.   Scars   round,    depressed,   thin,   non-adherent,    smooth, 

often  pigmented  at  first. 

271 


272     SYPHILIS    OF    THE   SKIN:    GENERAL    CHARACTERISTICS 

II.  Early  eruptions  disseminated  and  profuse,  later  ones 
asymmetrical  and  grouped. 

Slow  and  Progressive  Development. —The  earlier  and 
more  generalized  the  eruption  the  more  rapidly  does  it  develop. 
A  general  macular  or  papular  syphilid  covers  the  man  in  a 
few  days ;  but  a  late  tuberculo-ulcerative  lesion  may  take  weeks 
to  develop  its  true  character. 

Much  more  striking  is  the  progressive  development  of  the 
lesions.  With  various  degrees  of  speed,  but,  as  a  rule,  slowly 
and  gradually,  the  eruption  spreads.  The  superficial  general 
eruption  spreads  by  the  appearance  of  new  lesions;  the  later 
single  lesions  by  encroaching  on  the  surrounding  tissues. 

Polymorphism. — The  early,  general  eruption  develops 
progressively  in  type  as  well  as  in  multiplicity  of  lesions. 
Thus  a  general,  papular  eruption  a  week  old  may  show  mac- 
ules, papules,  tubercles,  vesicles,  pustules,  and  minute  ulcers 
irregularly  intermingled.  Such  is  polymorphism.  It  is  all 
but  pathognomonic  of  syphilis. 

The  later  the  eruption  the  less  polymorphic  is  it  likely  to  be. 

Absence  of  Inflammation. — Fever  very  rarely  accompa- 
nies a  syphilitic  eruption.  Exceptions,  chiefly  due  to  absorp- 
tion from  mixed  infection  of  a  pustular  syphilid,  are  so  few 
as  to  be  negligible. 

Neither  is  tenderness,  heat,  nor  inflammatory  congestion 
discernible  in  the  lesion  itself.  It  develops,  as  the  French  say, 
a  froid. 

Absence  of  Pain  and  Itching. — The  syphilitic  lesion  as 
such  is  painless.  In  those  exceptional  instances  (and  they  are 
singularly  rare)  of  mixed  infection  with  the  ordinary  pyogenic 
microbes,  the  pain  is  due  to  the  adventitious  inflammation. 

Moreover,  the  syphilid  does  not  itch.  A  little  tingling 
may  accompany  the  relatively  rapid  development  of  a  diffuse 
exanthem,  but  even  this  is  rare  and  does  not  amount  to  a  real 
itch. 


GENERAL    CLINICAL    CHARACTERISTICS  273 

But  confusing  complications  are  many.  A  seborrheal  scalp 
is  always  rather  itchy,  and  a  syphilitic  eruption  upon  it  may 
render  this  tendency  more  pronounced.  Hence  slight  itching 
in  an  eruption  of  the  scalp  must  always  be  discounted. 

Parasitic  eruptions  and  eczema  are  not  the  less  pruriginous 
for  being  associated  with  syphilis,  and  a  skin  wdiich  is  nor- 
mally irritable  and  itchy  is  no  less  so  when  covered  with  a 
syphilid. 

Peculiar  Color. — The  color  of  the  syphilids  is  not  a  frank, 
inflammatory  red,  but  a  vinous,  empurpled  redness,  resem- 
bling, when  well  marked,  the  raw  meat  of  ham.  This  color  is 
found  also  in  many  of  the  gouty,  papular  eruptions  and  in 
psoriasis,  rarely  in  other  eruptions.  The  color  of  the  syphilids 
passes  by  pigmentation  from  this  dusky  red  into  a  yellowish 
copper  color,  and  sometimes  by  a  deep  pigmentation  to  brown 
or  black,  the  skin  around  the  lesion  (areola)  being  usually 
also  pigmented  to  a  certain  extent.  This  pigmentary  colora- 
tion sometimes  lingers  for  years,  but  usually  clears  off  after 
a  few  months,  disappearing  first  centrally,  then  peripherally. 
Finally,  the  spot  becomes  brilliantly  white. 

Rounded  Form. — Every  syphilid  is  composed  of  circular 
lesions.  If  discrete,  as  in  most  of  the  earlier  eruptions,  the 
individual  lesions  are  manifestly  round.  But  many  of  the  later 
lesions  are  confluent.  Either  because  the  lesions  begin  so  close 
together  or  because  in  spreading  they  invade  the  same  terri- 
tory, the  resultant  lesion  is  a  composite  one,  and  this  may  show 
a  circinate,  polycyclic  edge,  which  is  very  characteristic. 

Moreover,  although  the  disposition  of  the  first  general 
eruptions  is  diffuse  and  irregular  (though  symmetrical),  the 
lesions  composing  later  eruptions  are  often  distributed  in  cir- 
cles or  in  segments  of  circles. 

Finally,  certain  of  the  more  chronic  syphilids  as  they  pro- 
gress extend  in  every  direction  toward  the  periphery,  healing 
at  the  same  time  in  the  center.     Hence  result  lesions  of  a  cir- 


2  74     SYPHILIS    OF    THE    SKIX:   GENERAL   CHARACTERISTICS 

cular   or   circinate   or   horseshoe   shape   quite  pathognomonic. 
Such  eruptions  are  cahed  serpiginous. 

The  Scale. — The  scales  on  the  cicatrices  and  on  the  patches 
of  scaly,  syphihtic  eruptions  are  thin,  ^vhite,  non-adherent, 
lamellar;  very  different  from  the  dense,  thick,  imbricated, 
adherent  scales  of  psoriasis. 

The  Crust. — The  scabs  formed  on  syphilitic  ulcerative, 
rupial,  and  pustular  lesions  are  rough  and  adherent,  dark 
brown,  or  greenish  black,  sometimes  loosened  by  an  underlying 
accumulation  of  pus,  but  more  often  seemingly  set  into  the 
skin,  and  tightly  adherent.  They  may  be  of  light  color  over 
secondary  pustular  lesions,  but,  light  or  dark,  the  green  hue 
is  rarely  totally  absent  and  is  often  brilliantly  marked. 

The  Ulceration. — With,  the  exception  of  the  chancre  and  of 
the  ulcerated  mucous  papule  (both  of  Avhich  may  vegetate 
and  are  usually  elevated  rather  than  depressed),  the  ulcerations 
of  syphilis  resemble  chronic,  indolent  ulcers.  They  are 
rounded  or  oval,  with  abrupt  edges  cut  away  like  those  of  a 
chancroid;  the  base  is  covered  with  yehovish,  false  membrane, 
sometimes  bkiish,  Hke  boiled  sago.  The  edges  and  base  of  the 
ulcer  are  usually  hard,  and  the  former  generally,  but  not  in- 
variably, firmly  adherent  and  not  undermined,  as  in  the  ulcer- 
ations of  tuberculosis.  These  ulcers  do  not  bleed  easily,  are 
generally  atonic  and  sluggish,  and  usually  entirely  painless. 
Apparent  exceptions  to  the  rule  in  regard  to  pain  are  often 
due  to  the  dependent  position  or  other  cause  calculated  to  excite 
inflammation,  or  to  the  situation  of  the  ulcer  over  a  bone,  the 
periosteum  of  which  is  inflamed  and  painful. 

The  Scar. — The  cicatrices  of  such  syphilitic  lesions  as  have 
destroyed  tissue  (i.  e.,  tertiary  lesions),  whether  there  has  been 
surface  ulceration  or  not,  are  rounded,  very  thin,^  depressed, 
smooth,  shining,  and  non-adherent.     They  are  usually  at  first 


'Marked  only, with  the  slightest  irregularities  (like  cigarette  paper). 


GENER.\L    CLINICAL    CHARACTERISTICS  275 

uniformly  pigmented  of  a  dark-brown  hue  (nearly  black  in 
brunettes).  This  pigment  clears  off  from  the  center  to  the 
circumference  until  only  a  dark  border  is  left,  which  some- 
times lasts  for  years,  but  finally  the  whole  cicatrix  acquires  an 
almost  pearly  whiteness  (though  the  pigmentation  may  per- 
sist indefinitely). 

Cicatrices  over  bone  adhere  if  they  have  been  connected 
with  bone  lesions.  The  cicatrices  left  by  an  ulcer  partaking  of 
the  nature  of  both  syphilis  and  tuberculosis  are  often  complex ; 
i.  e.,  the  scar  is  irregular,  uneven,  bridled  on  its  surface,  con- 
tracted in  parts,  adherent  at  points,  not  much  pigmented — 
possessing,  in  a  word,  the  characteristics  of  a  tubercular  cica- 
trix rather  than  those  of  syphilis.  Such  complex  cicatrices 
are  seen  where  syphilitic  glands  have  undergone  tubercular 
caseation. 

GENERAL    CLINICAL    CHARACTERISTICS   OF    SECONDARY   AND 
TERTIARY    SYPHILIDS 

Certain  general  clinical  characteristics  distinguish  the  sec- 
ondary from  the  tertiary  syphilids. 
The  secondary  lesions  are : 

1.  Superficial,  benign,  resolutive.  .        (_ 

2.  Multiple,  profuse,  or  even  generalized. 

3.  Irregularly  disseminated,  but  usually  symmetrical. 

4.  Polymorphous. 

5.  Curable  by  mercury. 
The  tertiary  lesions  are : 

1.  Deep,  destructive,  and  malignant. 

2.  Few  in  number,  often  single. 

3.  Distributed  in  circles  or  segments  of  circles,  and  usually 
asymmetrical. 

4.  Usually  monomorphous. 

5.  Usually,  though  not  always,   require  mixed  treatment 

for  a  cure. 
20 


276     SYPHILIS    OF   THE    SKIN:   GENERAL    CHARACTERISTICS 

I.  The  secondary  lesions  are  superficial,  benign,  and  reso- 
lutive; the  tertiary  lesions,  deep,  destructive,  and  malignant- 
These  characteristics  are  the  common  distinguishing  ones  be- 
tween all  secondary  and  all  tertiary  lesions,  whether  in  the 
skin  or  elsewhere.  But  the  distinction  is  peculiarly  marked 
in  syphilis  of  the  skin.  No  contrast  could  be  greater  than  that 
between  a  general  roseola,  for  instance,  which  covers  the  trunk 
with  a  blush  that  lasts  only  a  few  days  and  disappears  spon- 
taneously,' and  an  ulcerative  lesion  driving  deep  through  the 
skin  and  into  the  subcutaneous  tissue,  advancing  slowly  and 
impartially  in  every  direction,  destroying  the  skin  before  it, 
and  showing  no  tendency  to  recover  spontaneously. 

It  must  not  be  forgotten,  however,  that  certain  secondary 
lesions,  notably  the  scaly  ones,  not  only  fail  to  get  well  sponta- 
neously, but  are  very  rebellious  to  treatment ;  while,  exception- 
ally, one  encounters  a  patient  whose  tertiary  lesions,  long  neg- 
lected, have  finally  healed  spontaneously,  though,  as  a  rule,  this 
healing  of  one  lesion  is  accompanied  by  the  outbreak  of  others. 

2v  The  secondary  lesions  are  multiple,  profuse,  or  even 
generalized,  while  the  tertiary  are  few  in  number  and  often 
single.  This  rule  must  be  accepted  broadly.  The  average 
tertiary  syphilid  is  made  up  of  fewer  le-sions  than  the  average 
secondary  lesion.  Yet  a  single  papule  may  be  no  less  sec- 
ondary for  being  unique;  while  multiple  gmnmata  of  the  skin 
lose  none  of  their  tertiary  malignancy  through  being  numer- 
ous; and  an  early  general  tubercular  syphilid  is  tertiary  in 
spite  of  time  and  multiplicity. 

3.  The  secondary  lesions  are  irregularly  disseminated,  but 
usually  symmetrical.  The  tertiary  lesions  are  distributed  in 
circles  or  segments  of  circles  and  usually  are  asymmetrical. 

The  elements  of  a  generalized  secondary  syphilid,  though 
symmetrically  distributed  in  that  they  affect  similar  parts  of 
the  body  on  opposite  sides,  are  not  grouped  in  any  geometric 
form ;  and  the  later,  less  generalized,  secondary  lesions,  though 


PLATE    VI. 


PLATE  VI.— The  Onset  of  Syphilis. 
Chancre  on  left  side  of  foreskin,  adenitis  in  left  groin,  maculo-papular  (poly- 
morphous) eruption.     (Piffard.) 


GENERAL    CLINICAL    CHARACTERISTICS  277 

they  tend  more  and  more  to  group  themselves  in  circles,  are 
usually  quite  irregularly  distributed.  Tertiary  lesions,  on  the 
other  hand,  whether  (as  already  described)  because  of  the 
original  distribution  of  the  lesions  or  because  of  their  destruc- 
tive advance  from  the  center  outward,  adhere  closely  to  the 
circular  or  polycyclic  type;  and,  though  tertiary  syphilids  oc- 
curring within  the  first  two  or  three  years  of  the  disease  are 
often  symmetrical,  the  later  the  lesion  the  less  is  this  sym- 
metry to  be  looked  for,  and,  generally  speaking,  it  is  not  char- 
acteristic of  the  tertiary  syphilid. 

4.  The  secondary  lesions  are  polymorphous;  the  tertiary 
lesions,  monomorphous.  This,  again,  is  a  relative  distinction, 
for  nothing  could  adhere  more  closely  to  a  single  type  than 
(for  example)  the  typical  squamous  secondary  syphilid  of  the 
palm,  while,  exceptionally,  various  tertiary  lesions  appear 
simultaneously  and  even  coincide  with  secondary  lesions  in 
other  parts  of  the  body. 

5.  The  secondary  lesions  are  curable  by  mercury,  while  the 
tertiary  lesions  usually,  though  not  always,  require  mixed 
treatment  for  a  cure.  This  rule,  as  far  as  the  secondary  syphi- 
lids are  concerned,  is  practically  universal :  one  does  not  see 
them  cured  by  iodid. 

But  in  the  treatment  of  tertiary  syphilids  it  is  often  diffi- 
cult to  determine  beforehand  which  of  the  two  drugs,  iodid  or 
mercury,  will  effect  a  cure.  Phagedenic  or  gummy  lesions  are 
usually  to  be  attacked  by  iodid.  This  checks  their  advance, 
and  heals  them  partially  or  w-holly,  but  to  maintain  the  cure 
mercury  must  be  administered.  On  the  other  hand,  the  more 
superficial  ulcerative  and  tubercular  lesions  often  do  better 
under  high  doses  of  mercury,  though  here  the  rule  is  by  no 
means  universal.  I  have  seen  similar  lesions  in  different  pa- 
tients get  well ;  in  the  one  under  iodid  after  mercury  admin- 
istered for  many  months  had  failed ;  in  the  other,  under  mer- 
cury after  iodid  administered  for  several  years  had  failed. 


278    SYPHILIS   OF   THE   SKIN:    GENERAL   CHARACTERISTICS 

The  best  rule  is  to  give  mixed  treatment.  If  this,  in  mod- 
erate doses,  fails  to  cure,  push  the  one  drug  to  the  point  of 
toleration,  and  then,  dropping  that,  push  the  other  to  the  point 
of  toleration.  Thus  you  will  find  which  may  be  expected  to 
effect  the  cure. 


GENERAL   PATHOLOGICAL   CHARACTERISTICS 

We  need  not  repeat  what  has  been  said  in  a  previous  chap- 
ter concerning  the  general  pathological  characteristics  of  syphi- 
lis. Suffice  it  to  say  that,  in  the  skin  the  papule  is  the  type  of 
all  secondary  syphilids,  the  tubercle  that  of  tertiary  syphilids, 
and  the  gumma  that  of  subcutaneous  syphilis. 

The  syphilitic  papule  is  an  exudation  beginning  in  a  papilla 
of  the  derma.  "  The  papule  is  prominent  because  there  is  a 
cellular  infiltration,  hard  because  this  infiltration  is  dense, 
brilliant  because  the  epidermis  is  tense  over  the  summit,  sur- 
rounded by  a  scaly  collar  because  the  epidermis  breaks  under 
the  effect  of  this  tension,  red  because  of  extravasated  blood." 

The  mucous  layer  of  the  skin  is  thickened  by  infiltration, 
the  papillae  are  hypertrophied,  and  the  epidermis  is  desquamated 
or,  in  the  squamous  papule,  thickened.  The  dilatation  and 
obliteration  of  the  vessels,  the  infiltration  of  their  wallSj  and 
the  perivascular  exudations  extend  well  into  the  subcutaneous 
connective  tissue.  Indeed,  the  prominence  of  the  papule  above 
the  surface  is  due  chiefly  to  the  subdermal  congestion  and 
edema.  Fig.  9  will  serve  to  illustrate  the  pathology  of  the 
syphilitic  papule  as  well  as  the  chancre. 

The  macular  syphilid  might  be  described  pathologically  as 
an  aborted  papular  eruption.  There  is  congestion  from  dilata- 
tion of  the  blood  vessels  and  slight  exudation ;  but,  unless  the 
macula  is  transformed  into  a  papule,  no  marked  exudate 
occurs. 

If  the  papule  becomes  squamous,  the  essential  change  is  a 


GENERAL    PATHOLOGICAL    CHARACTERISTICS 


279 


proliferation  and  desquamation  of  the  epidermis.  If  it  be- 
comes vesicular,  the  epidermis  is  raised  by  serum  exuded  into 
the  lesion.  If  pustular,  this  vesicle  is  filled  with  the  necrotic 
tissue  and  pus  cells. 

The  syphilitic  tubercle,  like  the  papule,  is  an  infiltration  of 
the  derma,  but  it  is  more  intense  and  deeper.  The  exudate, 
instead  of  being  confined  almost  exclusively  to  the  papillae, 
involves  the  whole  derma  and  the  subjacent  connective  tissue. 
The  syphiloma  resides  in  the  true  skin  instead  of  on  it.  Hence 
the  healing  is  accompanied  by  loss  of  tissue  in  the  skin,  and 
leaves  a  permanent  defect,  a  typical  syphilitic  scar  (Fig.  17). 


--^^^J  $■?>:'  ^  ^-"-^^-J V/v. 


Fig.  17. — Pathology  of  the  Syphilitic  Tubercle  (diagrammatic).  The 
lesion,  though  covered  with  epithelium  and  not  ulcerated,  has  destroyed  the 
true  skin  and  will  leave  a  scar.     Compare  Figs.  lo  and  36. 


The  subcutaneous  gumma  is  the  same  lesion  removed  to  a 
still  deeper  plane.  Instead  of  a  primary  focus  in  the  skin  with 
secondary  involvement  of  the  subcutaneous  tissue,  there  is  pri- 
mary involvement  of  the  subcutaneous  tissue  and  secondary 
extension  to  the  skin.  Vascular  dilatation  and  infiltration, 
interstitial  exudation,  and,  finally,  atrophy  and  caseation  are 
the  common  lesions  of  all  gummata. 


CHAPTER    XX 
SECONDARY  SKIN  SYPHILIDS 

In  describing  syphilis  of  the  skin  it  is  more  conven- 
ient to  group  together  those  lesions  which  affect  the  gen- 
eral integument  and  to  separate  in  another  chapter  those 
lesions,  such  as  mucous  papules,  condylomata,  eruptions  of 
the  scalp  and  onychia,  that  are  peculiar  to  special  parts 
of  it. 

The  division  of  skin  syphilis  into  secondary  and  tertiary 
lesions  is  relatively  unsatisfactory,  inasmuch  as  certain  lesions 
belong  to  an  intermediate  indeterminate  class.  They  have  some 
characteristics  common  to  the  secondary  lesions,  others  com- 
mon to  the  tertiary  lesions,  and  are  sometimes  curable  by  mer- 
cury, sometimes  by  iodid.  Yet,  on  the  whole,  it  is  more  con- 
venient to  maintain  the  distinction,  taking  the  papule  as  the 
basis  of  secondary  syphilis,  the  tubercle  as  the  basis  of  the 
tertiary  lesions. 

The  secondary  syphilids  affecting  the  general  integument 
may  therefore  be  discussed  under  the  following  heads: 

Macular  syphilids. 

Papular  syphilids. 

Vesicular  syphilids. 

Pustular  syphilids  (including  crusted  and  ulcerating 
lesions). 

Squamous  syphilids. 

Pigmentary  syphilids. 
280 


THE   MACULAR   SYPHILIDS 


281 


THE   MACULAR    SYPHILIDS 

The  important  macular  syphilid  is  that  general,  macular 
eruption  or  roseola  which  is  habitually  the  first  seen  of  the 
secondary  eruptions  of  syphilis  (Fig.  18). 


Fig.  18.— Macular  Syphilis.     (Fox.) 


Regions  Involved. — The  eruption  first  appears  upon  the 
loin    or    flanks    and    the    lateral    thoracic    regions.      Thence 


282 


SECONDARY   SKIN   SYPHILIDS 


it  extends  all  over  the  trunk,  and  to  a  less  degree  to 
the  extremities  affecting  chiefly  their  flexor  surfaces.  The 
head  and  hands  and  feet,  are,  happily,  almost  always 
spared. 


Fig.   19. — Labial  Chancre  and  Macular  Syphilid   (Face  Freckled, 
BUT  Free  from  Eruption).     (Fox.) 


THE    MACULAR    SYPHILIDS 


283 


Character  of  the  Eruption. — The  roseola  is  often  so  faint 
as  to  be  overlooked  by  the  patient.  I  have  several  times  had 
a  physician  bring  for  diagnosis  a  patient  covered  with  macules 


Fig.  20.— Maculo-papular  (Polymorphous)  Syphilid.     (Fox.) 


which  neither  the  victim  nor  his  doctor  had  been  able  to  dis- 
tinguish until  I  pointed  them  out.  But  usually  the  lesions  per- 
sist, become  more  and  more  evident,  and  at  last  are  unmistak- 
able even  by  the  patient. 


284  SECONDARY    SKIN    SYPHILIDS 

The  eruption  is  made  up  of  small  blotches,  varying  in 
size,  circular  or  crescentic  in  form,  with  slightly  indented 
margins.  The  average  size  is  that  of  a  split  pea.  Exception- 
ally, the  macules  are  very  small  or  they  may  be  an  inch  across. 
Macules  of  various  sizes  appear  on  the  same  individual.  Their 
color  is  rosy  and  not  at  all  a  ham  color  unless  they  have  ex- 
isted for  some  time,  when  they  may  take  on  a  certain  yellow- 
ish pigmentation.  They  disappear  on  pressure  unless  this  pig- 
mentation has  occurred,  in  which  case,  after  pressure,  they 
appear  as  light  yellow  spots.  On  healing  they  leave  a  light 
grayish  mark  if  they  have  been  pigmented.  Desquamation  is 
rare. 

Varieties. —  Polymorphous  Eruption.  —  This  is  the 
most  important  variation  of  the  simple  roseola.  Many  cases 
begin  with  roseola,  and  before  the  macules  disappear  a  certain 
number  of  them  become  papular,  and  gradually  the  macular 
gives  way  to  a  papular  eruption  (Figs.  20,  21). 

Meanwhile  the  papules  themselves  may  be  undergoing  fur- 
ther transformation  into  tubercle  or  pustule. 

Elevated  Macule. — In  some  cases  there  is  sufficient  ex- 
udation to  cause  a  distinct  elevation  of  the  macules  above 
the  surrounding  skin.  This  can  be  readily  discerned  by 
throwing  a  strong  light  at  an  acute  angle  upon  the  affected 
surface. 

Late,  Circinate,  Macular  Syphilid.— At  various  peri- 
ods during  the  course  of  the  disease  the  macular  syphilid  may 
relapse;  though  such  relapses  are  extremely  rare,  they  are 
none  the  less  characteristic.  When  they  occur  during  the  first 
year  they  may  be  quite  diffused,  but  in  later  years  the  macular 
syphilid  assumes  a  distinctly  circinate  form ;  it  is,  as  it  were, 
the  shadow  of  a  circinate  tubercular  lesion.  I  have  four  times 
seen  such  an  eruption  in  the  third  year  of  the  disease.  In 
one  patient  the  spots  occurred  upon  the  arm,  replacing  a 
sunburn. 


THE    MACULAR   SYPHILIDS  285 

Duration. — The  initial  roseola  covers  the  trunk  within  two 
or  three  days  of  its  inception,  and,  if  untreated,  lasts  from  two 
to  six  weeks;  but  under  treatment,  it  rapidly  disappears.  In 
many  cases  the  roseola,  if  untreated,  merges  into  the  succeed- 
ing papular  eruption. 


Fig.  21. — Back  of  Case  Shown  in  Fig.  20.     (I  ox.) 


286  SECONDARY    SKIN    SYPHILIDS 

Though  the  late  circinate  macular  syphilid  is  usually 
much  more  tenacious  than  the  earlier  eruption,  it  disap- 
peared rapidly  in  three  of  my  cases,  while  the  fourth  lasted 
a  year. 

Diagnosis. — The  distinguishing  characteristics  of  tlie  gen- 
eral macular  syphilid  need  no  further  description.  If  the  erup- 
tion is  faint  or  has  just  begun  to  appear,  it  may  be  much  bet- 
ter distinguished  by  looking  at  it  through  a  cobalt-blue  glass. 
The  best  light  for  this  examination  is  a  moderate  daylight, 
and  the  glass  should  be  held  close  to  the  eye  in  order  to  cut  out 
extraneous  rays. 

The  diagnosis  of  syphilis  should  be  further  enforced  by 
the  discovery  of  the  glands  and  perhaps  the  induration  re- 
maining at  the  site  of  the  primary  lesion,  while  concomitant 
lesions  inside  the  mouth,  epitrochlear  or  posterior  cervical 
nodes,  or  other  symptoms  of  the  onset  of  syphilis  may  be 
found  (Fig.  19). 

The  diagnosis  of  syphilis  may  not  be  made  on  the  roseola 
alone,  any  more  than  on  the  chancre  alone. 

Differential  Diagnosis. — The  roseola  may  be  distinguished 
from  that  of  measles  or  scarlatina  by  the  absence  of  fever  and 
by  the  concomitant  syphilitic  lesion  (of  the  upper  air  pas- 
sages, etc.). 

Drug  eruptions,  notably  those  due  to  copaiba  and  antipyrin, 
are  confluent,  inflammatory  and  itching,  usually  associated 
with  urticarial  lesions,  variously  distributed,  and  due  to  the 
taking  of  the  drug,  of  which  a  history  may  be  obtained. 

Simple,  or  springtime  roseola  itches,  usually  affects  the 
face, 'is  accompanied  by  fever  and  digestive  disturbances,  and 
appears  and  disappears  within  a  short  time.  Macules  due  to 
various  parasites  are  irregularly  distributed  and  intensely 
itchy.  The  natural  marbling  of  skin  due  to  cold  or  the  flush 
of  shame  can  scarcely  be  mistaken  for  syphilitic  roseola,  while 
the  itching  wheals  of  urticaria  are  equally  distinctive. 


THE    PAPULAR    SYPHILIDS 


287 


THE    PAPULAR    SYPHILIDS 

The  Papule. — The  syphilitic  papule  is  very  slightly  ele- 
vated above  the  surface  of  the  skin.  It  varies  from  the  size 
of  the  head  of  a  pin  to  that  of  a  split  pea.     Its  summit  is  flat, 


Fig.  22. — Papular  Syphilid:  Confluent  on  Face.     (Fordyce.) 


though,  if  the  papule  be  very  small,  this  feature  may  be  lack- 
ing. Its  shape  is  absolutely  and  characteristically  circular; 
its  color,  at  first  pink,  soon  takes  on  a  purplish,  ham  or  cop- 


288  SECONDARY    SKIN    SYPHILIDS 

per  hue  although  quite  frequently  this  is  not  marked,  but  may 
be  intensified  by  pressure.  Its  surface  is  shining  and  tense, 
and  this  may  be  covered  by  a  slight,  thin  scale,  or,  more  com- 


FiG.  23. — Papular  Syphilid,  Showing  Marked  Predilection  for  the  Back 
OF  the  Neck.     (Fox.) 

monly,  this  scale  is  promptly  shed,  leaving  a  faint,  scaly  collar 
around  its  base.    The  papule  is  hard,  and  has  in  some  measure 


THE    PAPULAR   SYPHILIDS 


289 


the  induration  characteristic  of  all  syphilitic  exudates. 
the  papule  all  the  other 
elerhents  of  se:cbndary 
skin  syphilis  arise,  and 
in  the  earlier,  papular 
eruptions,  it  is  not  un- 
common to  find  admix- 
tures  of  pustules,  squa- 
mous papules,  etc. 

Papular  Eruptions. 
—The  papular  syphil- 
id may  be  general  and 
disseminated  or  partial 
and  scattered.  In  a 
certain  proportion  of 
cases  the  general  mac- 
ular or  papular  erup- 
tion is  preceded  by  the 
appearance  of  a  few 
scattered  papules.  As 
a  rule,  however,  the 
first  papular  eruption 
is  generalized.  It  be- 
gins with  the  appear- 
ance of  scattered  pap- 
ules over  the  body,  and 
these  gradually  multi- 
ply until,  at  the  end  of 
a  week  or  two,  they 
cover  the  whole  sur- 
face of  the  body,  the 
trunk,  the  head,  the 
face,  and  the  extremi- 
ties.  The  papules  show 


From 


Fig.  24. 


-Papular  Syphilid  on  a  Negro. 
(Fox.) 


290 


SECONDARY    SKIN    SYPHILIDS 


no  tendency  to  grouping,  but  are  distributed  broadcast,  though 
in  the  costal  region  they  are  in  some  measure  aHgned  with 
the  sweep  of  the  ribs.  If  untreated  the  eruption  remains  for 
a  number  of  weeks  and  becomes  more  and  more  polymorphous, 
the  older  lesions  becoming  pustular,  squamous,  or  tubercular, 
while  new  papules  constantly  appear.  Ultimately  the  eruption 
will  disappear  spontaneously  in  most  instances,  though,  occa- 
sionally, if  untreated,  it  gradually  changes  to  a  persistent  ter- 
tiary type. 

Relapsing  papular  eruptions  tend  to  be  more  closely  con- 
fined to  certain  (indeterminate)  regions  the  later  they  occur. 
As  a  rule,  however,  the  papules  are  not  grouped  in  any  geo- 
metric figure;  they  remain  disseminated.  Even  those  later 
papular  eruptions  are  often  bilateral  and  symmetrical. 

Varieties. — The  Miliary  Papular  Syphilid. — In  this 
variety  the  papules  are  minute  and  pointed  and  grouped  in 
little  colonies  scattered  all  over  the  body.  It  develops  within 
three  or  four  days.  This  eruption  is  very  rare  and  quite  re- 
sistant to  treatment. 

The  Lenticular,  Papular  Syphilid. — This  is  the  usual 
type  described  above.  It  comes  out  more  slowly  than  the  mil- 
iary eruption,  and  often  occurs  in  successive  crops,  which  may 
recur  for  many  months.  Relapses  of  this  eruption  of  a  partial, 
disseminated,  or  circinate  type  are  very  common,  and  may 
occur  on  any  part  of  the  body.  A  peculiarly  striking  papular 
eruption  occurs  in  a  symmetrical  band  across  the  brow,  and  is 
known  as  the  corona  veneris. 

The  Nummular  Syphilid. — Exceptionally  the  papules 
are  extremel}^  large,  varying  from  the  size  of  a  dime  to  that 
of  a  cent.  The  eruption  is  a  late  one,  and  often  circinate. 
The  lesions  are  often  umbilicated  and  may  be  covered  with  a 
scale  which  adheres  in  the  center  and  is  detached  at  the  edges. 
These  nummular  patches  may  become  annular  by  healing  at 
the  center  and  leaving  a  persistent  indurated  ring. 


THE   PAPULAR   SYPHILIDS  29I 

To  distinguish  between  a  nummular  and  a  tubercular  syphi- 
lid may  be  clinically  impossible.  The  nummular  eruption  is 
a  (clinically  rare)  link  between  the  two  types.  But  in  healing 
the  tubercle  leaves  a  scar,  the  papule  does  not. 

The  Diffuse  Ixduratiox. — This,  like  the  nummular 
syphilid,  is  an  "  intermediate  "  lesion.  It  consists  in  irregu- 
lar, circinate  areas  of  infiltration.  It  is  rarely  seen  except  about 
the  mouth  and  nose  (page  312). 

The  Crusted  Papule  (see  page  292). 

The  Moist  Papule  (see  page  302). 

The  Scaly  Papule   (see  page  296). 

Diagnosis. — Apart  from  the  history  and  the  other  coinci- 
dent lesions  of  syphilis  (nodes,  mouth  lesions,  crusted  papules 
in  the  scalp),  the  distinguishing  characteristics  of  the  papular 
syphilid  are : 

Its  Distribution. — General,  relapsing,  and  polymorphous, 
or  regional  (diffused  or  circinate). 

Its  Character. — A  shotty,  dark-red,  perfectly  round,  flat- 
topped,  slightly  scaling  papule. 

Differential  Diagnosis. — The  general  papular  syphilid 
must  be  distinguished  from  lichen  planus.  The  papules  in  this 
disease  vary  greatly  in  size  (in  a  given  eruption),  are  not 
strictly  circular  in  form,  are  often  umbilicated  rather  than  flat- 
tened, and  may  be  covered  with  a  striated  scale.  There  is 
a  certain  tendency  to  linear  distribution.  Yet,  on  disappearing, 
the  papules  of  lichen  planus  leave  macules  which  may  give  a 
semblance  of  polymorphism  to  the  eruption  (though  in  lichen 
planus  the  macules  are  never  intermingled  with  the  papules), 
and  the  papules  itch  but  little,  with  an  occasional  brilliant 
exception  have  a  dusky  hue,  and  ma}^  be  grouped  in  a  circinate 
way.  The  diagnosis  may  thus  be  extremely  difficult,  and  may 
await  the  test  of  treatment  or  depend  upon  collateral  evidence. 

Psoriasis  is   closely   mimicked   by  the    squamous   papular 

syphiHd_(page  298). 
21 


292  SECONDARY    SKIN    SYPHILIDS 

The  corona  veneris  may  be  mistaken  for  acne,  but  the  dusky 
color  and  shotty  feel  and  flat  surface  of  the  syphilitic  papules 
distinguish  them  from  the  pointed,  tender,  inflammatory  acne 
lesions. 

THE    VESICULAR    SYPHILIDS 

The  appearance  of  a  vesicle  on  top  of  a  syphilitic  papule 
is  usually  but  a  step  toward  pustulation.  Varicelloid  and  her- 
petiform  syphilids  are  accordingly  more  appropriately  classi- 
fied as  pustular  syphilids. 

The  Bullous  Syphilid. — The  bullous  syphilid  or  syphilitic 
pemphigus  is  the  only  lesion  properly  vesicular,  and  since  it  is 
extremely  rare  in  acquired  syphilis  (some  authors  even  doubt- 
ing its  existence)  and  quite  common  in  the  hereditary  form 
of  the  disease,  its  description  is  more  appropriate  elsewhere 
(page  513)- 

THE    PUSTULAR   AND    CRUSTED    SYPHILIDS 

The  pustular  syphilids  are  all  (excepting  the  crusts  in  the 
scalp)  rare  secondary  lesions.  Pustuladon  is,  generally  speak- 
ing, excited  by  dirt  and  debility.  It  is,  therefore,  properly  re- 
garded as  an  evil  omen.  — 

The  pustule  is,  as  it  were,  superadded  to  a  syphilitic  papule 
and  sits  upon  it,  destroying  but  little  tissue,  and  hence  leaving 
little  or  no  scar.  Pustular  lesions  may  be  scattered  among  the 
papules  of  a  polymorphic  eruption,  but  the  more  notable  pustu- 
lar eruptions  are  those  which  follow  given  types  and  mimic 
certain  non-syphilitic  eruptions.     Accordingly,  we  distinguish : 

Herpetiform  syphilid. 
Varicelloid   (or  varioloid)    syphilid. 
Acneiform  syphilid. 
Impetiginous  syphilid. 
Ecthymatous  syphilid. 


THE    PUSTULAR   AND   CRUSTED    SYPHILIDS 


293 


Herpetiform  Syphilid. — Extremely  rare.  Constituted  by 
groups  of  minute  vesicles,  pustules,  or  crusted  papules.  The 
lesions  lie  very  close  together.  They  come  out  in  successive 
crops. 

Color  and  slowness  of  development  may  distinguish  this 
lesion  from  true  herpes,  though  the  mimicry  is  sometimes  per- 
fect. 

Varicelloid  Syphilid.^ Very  rare.  Occurs  early  in  the 
disease.  Upon  the  papules  arise  pointed,  round,  or  umbilicated 
vesicles,  surrounded  at  their  base  by  a  dark-red  areola  after- 
wards becoming  brown.  The  contents  of  the  vesicles  quickly 
become  purulent  and  dry  up  into  a  greenish  brown,  adherent 
crust.  This  scab  falls  in  about  a  fortnight,  leaving  a  purplish 
discoloration,  which  slowly  disappears.  There  are  usually  but 
few  spots  of  eruption  scattered  over  the  face,  limbs,  and  body. 
Successive  crops  of  vesicles  may  prolong  the  eruption  for  sev- 
eral months,  and  ordinarily  some  other  syphilid  coexists 
with  it. 

Diagnosis. — This  lesion,  occurring  soon  after  a  syphilitic 
fever,  and  itself  perhaps  accompanied  by  some  rise  of  tempera- 
ture from  absorption,  may  lead  to  a  diagnosis  of  small-pox. 
Such  mistakes  were  numerous  in  other  days  when  the  pustular 
syphilid  was  more  common,^  for  the  eruption  may  precisely 
imitate  that  of  variola.  The  mistaken  diagnosis,  whether  with 
variola  or  with  varicella,  cannot  long  continue  before  the 
atypical  course  of  the  eruption  and  fever  leads  to  a  fruitful 
investigation  of  the  patient's  history. 

Acneiform  Syphilid. — This  eruption  occurs  scattered  over 
the  scalp,  the  face,  and  the  extremities,  the  lower  rather  than 
the  upper — or  it  may  cover  the  whole  body.  Each  pustule  is 
distinct,  and  out  of  most  of  them  grows  a  hair.  They  are  not 
prominent,  usually  small,  often  but  little  larger  than  a  grain 

»  Cf.  Morrow,  /.  Cnt.  and  Venereal  Dis.,  1886,  March. 


294 


SECONDARY   SKIN   SYPHILIDS 


of  millet.  Each  separate  pustule  rests  on  a  syphilitic  papule, 
which  itself  never  suppurates.  The  pustule  slowly  grows,  tak- 
ing from  two  to  three  weeks  to  develop  and  harden  into  a  dry 


Fig.  25. — Papulo-pustiilar  (Acneiform)  Syphilid.     (Fox.) 

scab  (Fig.  25).  The  underlying  papule  has  meantime  been 
getting  brown  and  becoming  surrounded  by  a  copper-colored 
areola.  When  the  scab  falls  an  umbilicated  papule  persists. 
This  is  gradually  absorbed,  leaving  a  purplish,  pigmented  dis- 
coloration,  which  is   very  slow  to  disappear.      Sometimes   a 


THE    PUSTULAR   AND    CRUSTED    SYPHILIDS  295 

slight,  superficial  ulceration  remains.  This  is  followed  by  a 
minute,  round,  white,  depressed  cicatrix,  very  different  from 
the  puckered  scar  of  ordinary  acne. 

The  acnciform  syphilid  of  the  scalp  is  one  of  the  most  con- 
stant early  eruptions  of  syphilis.  It  corresponds  with  the  pap- 
ular syphilid  elsewhere  on  the  body.  It  has  the  general  char- 
acteristics just  described,  except  that  the  papule  is  relatively 
insignificant  and  the  lesion  is  usually  seen  in  the  crusty 
stage,  and  is  therefore  familiarly  spoken  of  as  "  scabs  in 
the  scalp." 

Acneiform  syphilid  is  rare  elsewhere  in  the  body  and  does 
not  usually  appear  until  several  months  after  the  first  erup- 
tion.    It  tends  to  relapse. 

Diagnosis. — "  Scabs  in  the  scalp,"  if  syphilitic,  are  thick- 
est on  top  of  the  head,  if  due  to  iodic  or  simple  acne  are  found 
only  in  the  occipital  region. 

The  acneiform  syphilid  is  distinguished  from  acne  vul- 
garis by  its  acute,  transitory  course,  its  irregular,  disseminated 
distribution,  its  essentially  papular  character  (while  acne  is 
essentially  pustular),  and  by  the  intermixture  of  simple,  syphi- 
litic papules. 

Iodic  acne  may  simulate  syphilitic  acne,  though  the  iodic 
pustules  are  usually  large,  sensitive,  and  inflammatory.  It 
may  be  necessary  to  desist  from  administering  the  iodid  in 
order  to  make  sure  of  the  diagnosis. 

Impetiginous  Syphilid. — Scattered  pustules  set  on  rather 
large  syphilitic  papules,  surrounded  by  an  areola,  constitute 
this  eruption.  The  pustules  are  superficial  and  soon  dry  to  a 
granular,  fragile,  yellow,  or  greenish  crust.  The  eruption 
occurs  most  frequently  about  the  face  and  scalp. 

Diagnosis. — These  lesions  may  be  quite  indistinguishable 
from  impetigo  contagiosa  except  by  their  less  indolent  course. 
But  other  syphilitic  lesions  almost  always  coexist  and  estab- 
lish the  diagnosis. 


296  SECONDARY  SKIN   SYPHILIDS 

Ecthymatous  Syphilid. — Syphilitic  ecthyma  may  be  sec- 
ondary or  tertiary  in  type.  In  the  latter  form  the  skin  is 
destroyed  by  deep  ulceration  (page  323).  In  the  superficial 
variety  the  lesions  resemble  those  of  the  impetiginous  syphilid, 
but  are  larger  and  more  often  found  upon  the  lower  extremi- 
ties, the  neck,  the  inguinal  and  gluteal  regions.  The  crusts  are 
also  darker,  denser,  and  more  adherent.  The  ulceration, 
though  superficial,  is  typically  syphilitic. 

Diagnosis. — Ecthyma  vulgaris  is  a  painful,  inflammatory 
lesion,  but  in  other  respects  is  quite  like  the  ecthymatous 
syphilid. 

THE    SQUAMOUS    SYPHILIDS 

Nearly  all  the  eruptions  of  syphilis  go  through  a  desqua- 
mative stage;  thus  a  patch  of  eruption  which  is  essentially 
papular,  tubercular,  or  pustular  may  finally  become  scaly,  and, 
remaining  so  for  a  considerable  time,  pass  for  a  squamous 
syphilid.  So  also  does  desquamation  occur  in  syphilis,  as  of 
the  scalp  with  early  alopecia ;  sometimes  in  little  patches  along 
the  margin  of  the  scalp  with  the  other  syphilids;  again,  with 
syphilitic  cachexia,  furfuraceous  desquamation  of  the  scalp,  or 
even  of  the  whole  body,  may  occur.  But  such  desquamation 
is  not  an  essentially  syphilitic  lesion ;  it  may  be  induced  by 
many  other  causes.  There  are,  however,  two  varieties  of  essen- 
tially scaly  syphilid.     These  are: 

Generalized  squamous  syphilid. 

Palmar  and  plantar  squamous  syphilid. 

Generalized  Squamous  Syphilid. — This  eruption  occurs  in 
two  varieties — as  a  guttate  or  diffuse  psoriasis  and  as  a  cir- 
cinate  eruption.  The  character  of  the  eruption  is  the  same  in 
each.  They  may  be  seen  together  on  the  same  subject.  The 
patches  vary  from  a  split  pea  to  a  penny  in  size — or  much 
larger  in  the  circinate  form — have,  as  a  rule,  the  deep  syphilitic 
color,  and  are  but  slightly  elevated  above  the  surface.     The 


THE   SQUAMOUS  SYPHILIDS 


297 


scales  are  white,  very  fine,  not  adherent,  not  imbricated  (as 
in  true  psoriasis)  (Figs.  26,  27).  After  a  few  weeks  the 
scales  fall,  to  be  replaced  by  others  finer  than  the  first,  and  thus 


Fig.  26. General  Papulo  s<,)Uami>us  Smmiti.id.     The  lesions  are  confluent  on 

the  face:  the  scaling  is  most  marked  about  the  shoulders.     (Fox.) 

several  desquamations  occur.     Finally,  the  color  pales  and  the 
lesion  disappears,  leaving  no  cicatrix,  provided  the  eruption 


2g8  SECONDARY  SKIN   SYPHILIDS 

has  not  been  a  tertiary  one  (tuberculo-squamous).     The  cir- 
cinate  form  starts  as  a  circle,  or  segment  of  a  circle,  inclosing 


PiG_    27.— Confluent    Papulo-squamous    Syphilid,    Resembling    Psoriasis. 

(Fordyce.) 


THE  SQUAMOUS  SYPHILIDS 


299 


healthy  skin,  does  not  generally  increase  in  size,  and  lasts 
from  a  few  weeks  to  some  months  (Fig.  28).  This  eruption 
is  a  late  one,  as  a  rule,  and  may  come  on  after  an  interval  of 
many  years. 

The  squamous  syphilid  appears  upon  the  trunk,  the  mem- 
bers, the  face,  and  along  the  forehead  at  the  edge  of  the  hair. 


Fig.    28. — CiRCiNATE    Papulo-squamotjs    Syphilid    of    Forearm.     (Fordyce.) 

It  shows  no  tendency  to  cluster  at  the  elbows  and  knees  and 
to  affect  almost  exclusively  the  extensor  surfaces  of  the  ex- 
tremities, as  does  psoriasis.  The  later  its  appearance  after 
chancre  the  more  chronic  its  course. 

Diagnosis.  — ■  When  not  associated  with  other  specific 
lesions,  the  squamous  syphilid  is  often  difficult  to  distinguish 
from  psoriasis.  Much  light  is  thrown  upon  such  cases  by  a 
study  of  the  previous  history  on  such  points  as  the  well-known 
inveterate  tendency  of  ordinary  psoriasis  to  relapse  and  its 
tendency  to  outbreak  in  the  spring  and  fall.  Neither  eruption 
itches,  and  both  have  the  same  livid  redness  of  color  under  the 
scales,  but  ordinary  psoriasis  tends  to  cluster  about  the  ell)ows 
and  knees  and  upon  the  scalp,  and  practically  never  affects  the 
palms  and  soles;  its  scales  are  thick,  imbricated,  tightly  at- 


300 


SECONDARY   SKIN   SYPHILIDS 


tached,  and  lying  in  several  layers,  so  that  it  is  difficult  to 
scrape  them  all  away  and  get  down  to  the  livid  redness  of  the 
patch  beneath;  and  when  the  scales  are  all  rudely  rubbed  off 
the  patch  is  very  apt  to  bleed. 

Common  lepra,  wdiose  scales  come  off  in  patches,  is  usually 
much  more  extensive  in  its  distribution  than  the  syphilitic 
eruption  and  of  indefinite  duration.  In  the  syphilitic  affection 
the  scales  are  more  lamellar^  finer,  less  adherent,  not  imbri- 
cated, or  in  thick  layers,  while  the  duration  of  the  eruption  is 
not  so  great.  Finally,  anti syphilitic  treatment  has  a  marked 
and  rapid  effect  in  the  one  form  while  it  does  not  modify  the 
other' 

The  circinate  form  in  some  of  its  stages  exactly  simulates 
ordinary  ringzuorm,  but  the  diagnosis  may  be  made  by  the 
absence  of  spores  and  by  watching  the  course  of  the  eruption 
which,  in  syphilis,  remains  stationary,  while  in  ringworm  a 
progressive,  centrifugal  enlargement  is  observed. 

The  Palmar  and  Plantar  Syphilid  (see  page  303). 

THE    PIGMENTARY    SYPHILID 

The  pigmentary  syphilid  is  one  of  the  rarest  skin  lesions 
of  the  disease.  It  appeslrs  almost  exclusively  in  women  be- 
tween the  fourth  and  the  twelfth  month.  It  seems  to  be  much 
rarer  in  the  United  States  than  in  Europe. 

The  typical  eruption  consists  of  a  pigmented  area  on  the 
side  of  the  neck  inclosing  a  multitude  of  white  islets  (Plate 
VII).     The  characteristics  of  the  eruption  are: 

1.  It  appears  spontaneously,  and  is  not  apparently  due  or 
in  any  way  related  to  any  other  syphilid. 

2.  The  islets,  though  they  appear  abnormally  white,'  have 
the  same  color  as  the  normal  skin;  the  apparent  whiteness  is 
an  optical  illusion.  This  may  be  proven  by  cutting  in  a  piece 
of  paper  little  holes  corresponding  to  the  white  patches :  the 


PLATE  VII  —Pigmentary  Syphilid  of  Neck.     (Musee,  St.  Louis.) 


THE    PIGMENTARY   SYPHILID  301 

paper  is  placed  over  the  lesion  so  as  to  hide  the  pigmented 
spots,  and  one  immediately  appreciates  the  normal  color  of 
the  white  islets. 

3.  The  disappearance  of  the  pigmented  spots  is  extremely 
slow,  and  is  apparently  unaffected  by  antisyphilitic  treatment. 
Though  most  authorities  believe  the  eruption  an  essential  or 
independent  lesion,  G.  H.  Fox  maintains  ^  that  he  has  watched 
it  grow  from  macules  upon  the  neck ;  macules  that  became 
pigmented  themselves,  and  then  gradually  faded,  leaving  the 
surrounding  area  pigmented. 

Diagnosis.- — This  typical  eruption,  looking  like  a  brown 
net  spread  over  the  side  of  the  neck,  is  unmistakable.  But  the 
eruption  may  appear  elsewhere  on  the  body  and  may  not  have 
the  reticular  distribution.  Such  instances  are  so  rare  as  to 
be  extremely  misleading.  Only  the  history  would  serve  to 
differentiate  them  from  idiopathic  or  cachectic  vitiligo. 

1  Ai7i.  J.  Med.  Sci.,  1S76,  p.  356. 


CHAPTER    XXI 

SECONDARY  SYPHILIDS  OF  SPECIAL  REGIONS  INCLUDING 

ONYCHIA 

Certain  syphilids  take  on  peculiar  qualities  from  the 
physical  influences  brought  to  bear  upon  them  in  certain 
special  localities. 

Taking  them  in  order  of  importance  we  shall  describe : 

Moist  papules,  erosions,  and  condylomata. 

Squamous  eruptions  of  the  palms  and  soles. 
J      Onychia  and  paronychia. 

Eruptions  in  the  scalp. 

Infiltrations  about  the  face. 

MOIST   PAPULES,   EROSIONS,   AND    CONDYLOMATA 

The  moist  papule  (erosive  papule,  mucous  papule,  patch, 
or  placjue)  and  its  associates,  the  erosion  and  the  condyloma, 
are  not  so  common  upon  the  skin  as  upon  the  mucous  mem- 
branes, though  extremely  frequent  about  the  genitals  of 
women ;  yet,  as  they  are  the  most  infectious  lesions  of  syphilis, 
except  the  chancre,  their  importance  cannot  be  overestimated. 

The  moist  papule  is  none  other  than  the  syphilitic  papule 
modified  by  its  surroundings.  It  occurs  only  upon  thin  skin, 
in  regions  lying  in  folds,  and  more  or  less  macerated  by  per- 
spiration. 

Hence  these  papules  are  relatively  common  upon  dirty  peo- 
ple, fat  people,  w^omen,  and  infants.  They  are  relatively  rare, 
in  fact,  extremely  rare  upon  thin,  clean  men.  Their  favorite 
302 


SQUAMOUS    ERUPTIONS    OF   THE    PALMS   AND    SOLES      303 

location  is  about  the  genitals  and  anus.  They  are  often  seen 
on  the  lips  and  within  the  female  genitals.  Less  common  loca- 
tions are  between  the  toes,  under  the  breasts,  in  the  axillae,  and 
elsewhere. 

The  moist  papule  is  the  same  flat,  slightly  elevated  lesion 
as  occurs  on  the  mucous  membranes,  though  sometimes  rather 
harder  in  consistence.  In  fact,  it  is  an  intermediate  lesion 
between  the  dry  papule  of  the  skin  and  the  moist  papule  of  the 
mucous  membrane,  and  bears  the  characteristics  of  the  one  or 
of  the  other  according  as  it  is  more  or  less  macerated. 

Accordingly,  they  are  best  described  with  the  secondary 
eruptions  of  the  mucous  membranes  (Chapter' XXIII). 

SQUAMOUS   ERUPTIONS   OF  THE   PALMS  AND   SOLES 

The  palms  and  soles  are  very  commonly  affected  by  syphi- 
lis, and  the  later  syphilitic  eruptions  in  these  regions  are  strik- 
ingly persistent  and  often  extremely  hard  to  cure. 

Early  disseminated  macular  (Fig.  29)  or  papular  erup- 
tions and  later  ulcerative  and  gummatous  lesions  of  the  palms 
and  soles  have  no  noteworthy  peculiarity.  The  squamous 
eruptions  alone  deserve  mention. 

Among  137  cases  of  squamous  palmar  syphilid,  10  began 
in  the  first  year,  19  in  the  second,  38  in  the  third,  19  in  the 
fourth,  9  in  the  fifth,  15  in  the  sixth,  6  in  the  seventh,  4  in  the 
eighth,  and  3  in  the  ninth  year  of  the  disease;  9  between  the 
tenth  and  the  fourteenth  year  and  i  each  in  the  sixteenth, 
eighteenth,  twentieth,  twenty-second,  and  twenty-third  years. 
Of  these  lesions,  3  lasted  seven  years,  i  lasted  six,  3  lasted  five, 
3  lasted  four,  4  lasted  three,  6  lasted  two,  and  7  one  year.  As 
many  of  the  cases  w^ere  not  cured  when  last  seen,  in  some 
instances  the  duration  was  surely  longer.  Two  of  them 
were  not  finally  cured  until  the  twenty-fifth  year  of  the 
disease.     Eight  cases  relapsed,    i   after  seven  years'   interval 


304 


SECONDARY   SYPHILIDS    OF   SPECIAL    REGIONS 


(two  to  nine  years),  2  after  four  years,  the  others  at  shorter 
intervals. 

Plantar  syphilids  are,  doubtless,  somewhat  less  frequent 
than  the  palmar  eruptions,  yet  we  see  them  very  much  less 
frequently,  for  the  patient  does  not  complain  of  them  unless 
they  are  quite  severe.  I  find  records  of  24  cases  of  plantar 
syphilids,   14  of  them  occurring  at  the  same  time  as  palmar 


Fig.  29. — ^Macular  Syphilid  of  Palm.     (Fordyce.) 


eruptions.  Eighteen  of  these  cases  were  within  five  vears  of 
the  chancre,  2  in  the  sixth  and  twelfth  years,  and  i  in  the 
tenth,  eleventh,  thirteenth,  and  twenty-fifth  years.  One  re- 
lapsed in  the  third,  fourth,  and  sixth  5'ear ;  i  lasted  six,  i  five, 
and  I  two  years. 

These  figures  are  given  in  order  to  impress  the  importance, 
the  persistence,  and  the  lateness  of  these  lesions.  All  the  late 
secondary  lesions  of  the  palms  are  in  some  degree  sc[uamous. 


SQUAMOUS    ERUPTIONS    OF   THE    PALMS   AND    SOLES      305 

With  the  first  general  papular  eruption  there  is  often  involve- 
ment of  the  palms  and  soles  by  papules  little  more  scaly  than 


Fig.  30. — Squamous  Syphilid  of  Palm.     Note  circiriate  border  and  absence  of 
definite  papules.     (Fordyce.) 

those  elsewhere  on  the  body;  but  the  later  papular  lesions, 
exclusively  confined  to  the'  palms  and  soles,  come  out  much 


v^ 

■ 

I 

J^'^^'^ 

1 

•*4, 

^ 

■  h. 

J 

^^^^^^^^^^^^^^^^HHb^^iis^^  ' 

ilB 

"•■-i<to^^ 

I 

Fig.  31. — Fissured  axd  Ulcerated  Eczema  of  Palm,  Simulating  an  Ulcer- 
ating Syphilid.     (PilTard.) 


3o6        SECONDARY   SYPHILIDS   OP   SPECIAL   REGIONS 

more  slowly,  rise  very  little  above  the  surface  of  the  sur- 
rounding skin,  and  are  either  covered  with  a  thick  epidermal 
scale  or  else  surrounded  by  a  meshed  fringe  of  cracked,  des- 


FiG.  32. — Annxtlar  Papulo-squamous  Syphilid  or  Soles.     (Piffard.) 


quamated  epithelium.  Moreover,  the  papules  tend  to  agglom- 
erate in  masses  or  to  spread  over  the  hand  in  an  irregular 
circinate  way  (Figs.  30,  31). 

If  the  eruption  is  seen  when  it  first  comes  out,  its  papular 
quality  may  be  readily  recognized  in  the  manifest,  individual 
papules  or  in  the  sinuous  line  of  confluent  papules.  But  in  an 
aged  lesion,  even  if  it  be  only  a  few  months  old,  the  papules 


SQUAMOUS   ERUPTIONS   OF   THE    PALMS   AND   SOLES      307 

may  almost  entirely  disappear,  and  all  that  is  left  visible  is  the 
squamous  almost  scarlike  change. 

In  this  condition  the  eruption  may  continue  active  and 
spreading  in  a  circinate  way  for  many  years,  during  which 
time  an  occasional  papule  may  become  visible,  or  the  conflu- 


FiG.  ^^. — Papulo-squamous  Syphilid  of  Sole  with  Great   Thickening  of 
THE  Epithelium.     (Piffard.) 

ent  red  ribbon  may  show  itself  here  and  there.  But  the  general 
characteristic  of  the  eruption  is  a  purely  scaly  one.  The  scales 
follow  one  of  two  types.    In  the  more  common  form  they  pro- 

22 


3o8        SECONDARY   SYPHILIDS   OF   SPECIAL   REGIONS 

duce  glistening,  psoriatic-looking  spots  (papular,  nummular, 
or  serpiginous),  or  else  these  scales  fall,  and  there  remains  a 
glistening,  atrophied-looking  skin,  surrounded  by  a  rough, 
raised  edge  of  epithelium,  precisely  like  the  collarette  that  sur- 
rounded the  syphilitic  papule,  but  thicker  and  more  marked. 
In  its  mildest  type  this  form  of  the  lesion  may  simply  show 
little  punched-out  spots  scattered  over  the  palm — little  rings  of 
elevated  epithelium — while  the  graver  lesions  show  irregular, 
circinate  spots  covering  the  whole  palm.  In  the  earlier  cases 
both  palms  are  usually  affected. 

Another  form  of  scaly  syphilid  consists  in  the  heaping  up 
of  a  great  callus.  I  have  seen  this  more  commonly  about  the 
heel  (Fig.  t^t,)  than  anywhere  else,  but  most  authors  agree  it  is 
more  frequent  in  the  palm.  If  this  callus  is  dug  out  it  leaves 
f^uite  a  deep  pit,  which  rapidly  fills  in  again.  If  the  hands  or 
feet  are  much  used  while  in  this  diseased  condition,  ragged, 
intractable  fissures  result  (Fig.  31). 

On  the  fingers  the  lesions  show  either  on  the  palmar  sur- 
face or  along  the  interdigital  surfaces.  The  backs  of  the  hands 
and  of  the  feet  are  always  spared. 

Diagnosis. — So  closely  do  these  lesions  mimic  eczema 
(Fig.  31)  that  almost  all  of  the  rebellious  cases  that  have 
come  to  me  have  had  prolonged  treatment  for  that  disease. 

The  diagnosis,  though  difficult  and  sometimes  impossible 
without  the  test  of  treatment,  rests  on  the  following  distinc- 
tions:  Eczema  usually  itches  and  oozes  and  runs  over  on  the 
back  of  the  hand ;  syphilis  does  none  of  these. 

Eczema  often  exists  elsewhere  on  the  body;  syphilis  often 
leaves  traces  elsewhere,  or  at  least  a  history. 

Eczema  does  not  produce  the  syphilitic  papule  nor  syphi- 
lis the  diffuse,  reddened  area  of  eczema. 

The  edges  of  the  eczematous  patch  have  rarely  the  typical 
rounded  or  circinate  shape  of  the  syphilid. 

Psoriasis  is  so  extremely  rare  upon  the  hand  that  it  scarcely 


ONYCHIA   AND    PARONYCHIA  309 

enters  into  the  question.  Moreover,  when  it  does  occur,  there 
is  always  at  least  a  history  of  the  disease  elsewhere  in  the  body, 
and  lesions  may  be  found  clustered  about  the  elbows  and  knees. 

Treatment. — I  have  never  seen  iodid  do  this  lesion  any 
good.  Mercury  in  small  doses  cures  certain  of  the  milder 
lesions,  but  the  aged  ones  often  require  the  most  vigorous  treat- 
ment to  cure  them:  Intramuscular  injections  of  insoluble  mer- 
cury salts  demonstrate  their  superior  virtues  in  these  intract- 
able cases  more  brilliantly  than  on  any  other  lesion  I  know. 

The  following  local  applications  encourage  but  do  not 
effect  healing : 

3^   Ichthyol gr.  xv  ( i  gm. )  ; 

Ung.  acid  boracic oj    (30  gm.). 

or 

I^   Ung.  zinci  oxid, 

^      .  .      .      .     > aa 

Ung.  picis  liquid, 


ONYCHIA    AND    PARONYCHIA 

Secondary  syphilis  of  the  nails  is  fairly  common  in  the 
early  stages  of  the  disease,  and  I  have  seen  7  cases  of  paro- 
nychia in  late  years,  i  each  in  the  fifth,  sixth,  seventh,  twelfth, 
and  twenty -fifth  years  and  2  in  the  eighth  year.  The  nails  of 
the  fingers  are  much  more  commonly  affected  than  those  of  the 
toes.     The  lesions  are  usually  multiple  and  bilateral. 

Syphilitic  Onychia. — Onychia  occurs  in  four  forms: 

1.  Atrophic  onychia  (onysis  craqiiele  of  Fournier). 

2.  Partial  detachment  of  the  nail. 

3.  Total  detachment. 

4.  Hypertrophic  onychia. 

Atrophic  Onychia. — This  is  quite  common  in  early 
syphilis.  If  slight,  the  nail  is  simply  thin,  ragged,  brittle,  and 
easily  broken ;  if  severe,  the  corners  of  the  nail  thicken,  the 


3IO 


SECONDARY  SYPHILIDS    OF   SPECIAL    REGIONS 


nail  itself  is  marked  by  pearly  ridges,  and  is  constantly  break- 
ing and  tearing  away  from  the  nail'  bed. 

This  more  severe  condition  is  almost  always  associated 
with  paronychia  and  due  to  it.  The  milder  form  afifects  all 
the  nails,  and  is  not  a  condition  peculiar  to  syphilis.  It  may  be 
caused  by  any  severe  systemic  infection. 

Partial  Separation  of  the  Nail. — -This  is  an  uncom- 
mon, fairl}-  early  lesion  associated  with  palmar  syphilids.  The 
whole  edge  of  the  nail  from  top  to  bottom  is  gradually  ele- 
vated from  its  base,  and  at  the  same  time  usuallv  rather  thick- 
ened. It  is  due  to  lesions  immediately  under  the  elevated  por- 
tion. 

Total  Detachmext. — If  the  disease  is  in  the  matrix 
itself,  it  may,  without  causing  paronychia,  cause  a  transverse 
total  detachment  of  the  nail.     This  is  quite  unusual. 

Hypertrophic  Onychia  is  extremely  rare.  It  consists  of 
an  extraordinary  thickening  of  the  nail  itself,  and  is  comparable 
to  that  form  of  palmar  S3'philis  in  which  great  callous  accumu- 
lations of  epidermis  occur. 

Other  A^arieties. — Fournier  has  described  a  type  of  de- 
structive ulceration  of  the  nail.  Taylor  has  noted  the  occur- 
rence of  little  pittings  on  the  surface  of  the  nail.  Hutchinson 
has  described  individual  variations  of  the  atrophic  onychia. 

Diagnosis. — Syphilitic  ouAxhia  is  often  mistaken  for  an 
eczematous  condition  from  which  it  may  be  distinguished  by 
the  absence  of  the  cracked,  oozing,  eczematous  lesions. 

Paronychia.  —  Three  forms  are  distinguished:  dry  paro- 
nychia, inflammatorA-  paronychia,  and  ulcerating  paronychia. 

In  the  dry  or  squamous  type  lesions  resembling  the  active 
squamous  syphilids  of  the  palm  surround  the  ridge  of  the  nail. 
There  is  often  great  thickening  of  the  epidermis  and  much 
cracking. 

In  the  iu^aiuiuatory  type  the  bed  of  the  nail  is  much  in- 
flamed, thickened,  and  painful.     At  first  sight  it  closely  resem- 


ERUPTIONS    IN   THE   SCALP  31 1 

bles  surgical  paronychia,  but  may  be  readily  distinguished  by 
its  chronic  course,  its  extremely  slight  tendency  to  suppurate, 
and  the  absence  of  cellulitis  or  fever. 

Ulcerating  paronychia  is  extremely  rare.  It  consists  of  a 
ragged  ulceration  about  the  base  of  the  nail  from  which  there 
is  usually  considerable  exuberant  granulation. 

Treatment. — Local  applications  of  mercurial  ointment 
or  plaster  have  a  slightly  beneficial  effect  upon  the  graver 
forms  of  onychia  and  paronychia.  Inasmuch  as  the  patient 
has  to  wear  a  glove-finger  to  protect  the  nail,  it  is  perfectly 
feasible  to  make  such  local  applications,  though  the  danger  of 
irritating  the  skin  should  be  borne  in  mind.  I  prefer  to  use 
one  of  the  simple  soothing  ointments  referred  to  above. 

The  progress  of  these  lesions  is  extremely  slow,  and,  like 
the  palmar  syphilid,  they  may  require  hypodermic  medication. 
It  is  futile,  however,  to  attempt  to  cure  the  condition  of  the 
nail  as  such.  If  the  lesions  in  the  matrix  or  in  the  bed  of  the 
nail  have  resolved,  the  nail  will  ultimately  become  normal,  but 
may  take  many  months  to  do  so. 

ERUPTIONS    IN    THE    SCALP 

Pustular  or  Crusted  Syphilid. — As  already  stated,  the  gen- 
eral papular  syphilid  shows  itself  on  the  scalp  as  a  pustular 
lesion,  which  promptly  becomes  crusted.  Little  papules  cov- 
ered with  crust  can  almost  always  be  found  disseminated  over 
the  scalp  in  connection  with  a  diffuse  papular  or  pustular 
syphilid.  These  so-called  scabs  in  the  scalp,  though  in  them- 
selves not  very  typical,  are  absolutely  characteristic  of  syphi- 
lis when  found  in  connection  with  a  syphilitic  eruption  of  the 
body  (page  120). 

Vegetating  Syphilid. — If  the  patient  does  not  keep  his 
scalp  clean  these  crusted  lesions,  instead  of  healing,  may  con- 
tinue to  ulcerate,  grow  larger,  and  finally  throw  out  exuberant 


312       SECONDARY   SYPHILIDS   OF   SPECIAL    REGIONS 

vegetations.  Such  an  eruption  is  not  peculiar  to  syphilis,  and 
quite  strikingly  resembles  the  essential  lesion  of  the  tropical 
disease  called  framhocsia  or  yaws  (page  122).  In  syphilis, 
however,  these  vegetations  are  not  widespread  and  are  almost 
exclusively  confined  to  the  hairy  portions  of  the  body,  and  to 
such  folds  in  the  skin  as  are  bathed  in  acrid  secretions. 


ERUPTIONS    ABOUT    THE    FACE 

Corona  Veneris. — This  common,  late  eruption  has  been 
already  described  (page  290).  The  corona  may  be  either  pap- 
ular or  tubercular. 

Diffuse  Infiltration. — Diffuse  infiltrations  about  the  lips 
and  nose  are  fairly  common.  They  are  due  to  the  confluence 
of  numerous  papules  and  are  quite  rebellious  to  treatment. 
They  form  thick,  circinate  infiltrations  of  the  skin,  dark  red, 
scaly,  or  ulcerated.  This  eruption  may  be  curable  by  mercury 
alone  or  may  require  high  doses  of  iodid.  It  is  impossible, 
except  by  the  test  of  treatment,  to  distinguish  in  a  given  case 
whether  the  eruption  is  secondary  or  tertiary. 

Vegetations. — Little  condylomata  may  occur  upon  the 
hairy  regions  of  the  face  and  in  the  creases  of  the  ala  nasi  and 
of  the  lips. 


PLATE   VUL— Tubercular  Syphilid. 

The  eruption  consists  of  (a)  isolated  tubercles,  (b)  masses  formed  by  the  con- 
fluence of  several  tubercles,  and  fc)  pathognomonic  circular  and  polycyclic  lesions. 
(Musee,  St.  Louis.) 


CHAPTER    XXII 
TERTIARY  SYPHILIDS  OF   THE  SKIN 

The  syphilitic  tubercle  is  to  tertiary  skin  syphilis  what  the 
papule  is  to  secondary  skin  syphilis.  Yet  it  is  difficult  to  draw 
the  line  between  the  two.  Some  of  the  nummular  and  irregu- 
lar infiltrative  and  eczematoid  lesions  described  in  previous 
chapters  lie  upon  the  border  line  between  secoAdary  and  ter- 
tiary lesions,  and  it  may  be  quite  impossible  to  state  before- 
hand that  a  given  case  will  be  curable  by  mercury  rather  than 
iodid,  or  that  it  will  not  leave  a  scar.  Indeed,  certain  lesions 
begin  with  apparently  innocent  papules,  and  these  more  or  less 
rapidly  develop  into  tubercles,  and  perhaps  finally  break  down 
as  gummata. 

The  pathological  difference  between  papule  and  tubercle 
consists  in  this :  The  papule  is  an  exudation  rather  upon  than 
in  the  true  skin.  It  does  not  destroy  any  of  the  tissue  of  the 
skin,  therefore  it  does  not  leave  a  scar.  The  tubercle,  on  the 
other  hand,  is  an  exudation  within  the  derma  which,  upon 
healing,  leaves  a  permanent  scar  (see  page  279). 

Tertiary  syphilids  of  the  skin  are  made  up  of  various  tuber- 
cular, tuberculo-pustular,  tuberculo-ulcerative  lesions,  and  of 
gummatous  lesions.  "  The  tubercle  may  be  described  as  a 
gumma  of  the  skin,  and,  conversely,  the  gumma  as  a  deep 
tubercle  of  the  connective  tissue"  (Morrow). 

Thus  tertiary  syphilids  ma,y  be  divided  as  follows : 

Tubercular  lesions. 

Tuberculo-ulcerative  lesions,  and 

Subcutaneous  gummata. 


314  TERTIARY    SYPHILIDS    OF    THE    SKIN 

THE    TUBERCULAR    SYPHILID. 

The  non-ulcerative,  tubercular  syphilid  occurs  under  two 
forms : 

The  disseminated  tubercular  syphilid  and 

The  grouped  tubercular  syphilid. 

Either  of  these  may  be  scaly  upon  the  surface  (tuber- 
culo-squamous). 

The  Tubercle. — The  tubercle  is  a  deep  infiltration  of  the 
true  skin.  Its  \'olume  varies  from  that  of  a  small  pea  to  that 
of  a  dime,  or  larger.  It  has  the  characteristic  dark-red  color 
common  to  syphilitic  skin  lesions; "it  is  tense  and  shining  upon 
the  surface,  though  it  may  be  covered  with  a  scale.  Its  top  is 
rounded  or  flattened  or  even  slightly  concave.  It  is  hard  to 
the  touch,  and  is  embodied  in  the  skin. 

The  Disseminated  Tubercular  Syphilid. — A  general- 
ized, tubercular  eruption  may  be  one  of  the  first,  general  erup- 
tions to  appear;  but,  as  a  rule,  the  tubercles,  though  dissem- 
inated, are  confined  to  a  given  region  of  the  body. 

The  tubercles  are  usually  small.  Their  favorite  positions 
are  on  the  forehead  (circle  of  \>nus),  the  lips,  the  back,  the 
leg,  the  outer  surface  of  the  forearm,  and  the  back  of  the 
shoulders.  A  single  tubercle  may  constitute  the  whole  erup- 
tion or  there  may  be  great  numbers  of  them. 

The  Grouped  Tubercular  Syphilid.  —  The  favorite 
locations  for  the  grouped  lesions  are  those  just  mentioned. 

The  grouping  occurs  in  three  forms : 

1.  The  discrete  form. 

2.  The  confluent,  circinate  form  (Figs.  34,  35). 

3.  The  massed  form. 

If  discrete,  the  tubercles  appear  to  be  ranged  in  circles  or 
in  arcs  of  circles,  forming  a  polycyclic  or  circular  design.  If 
confluent  they  form  sinuous  scalloped  figures,  or  else  a  solid, 
rounded,  indurated  mass. 


THE    TUBERCULAR    SYPHILID 


315 


As  the  tubercles  may  come  out  in  successive  groups,  one 
sees  them  in  different  stages  of  their  evokition;  some  small, 
dark  red  and  tense;  others  larger,  flatter,  shriveling,  and  a 
little  scaly  on  the  surface.  Exceptionally,  as  the  tubercle  heals, 
the  center  becomes  normal,  and  there  remains  for  a  while  a 


Fig.  34. — Confluent  Tubercitlar  Syphilid  of  Nose.     (Fox.) 

little  indurated  circle  around  a  central  scar.  As  complete 
healing  occurs,  there  is  formed  a  flat,  thin,  depressed  syphilitic 
scar,  which  is  usually  pigmented  for  some  months. 

The  progress  of  the  lesions  is  often  very  slow  even  under 
treatment.  If  untreated,  the  eruption  may  be  serpiginous,  in 
that  the  first  tubercles  gradually  disappear  and  new  ones  spring 


:'iG.  35. — Serpiginous  TuBERCxn^AR  Syphilid.     (Morrow.) 
316 


THE    TUBERCULAR    SYPHILID 


317 


up  about  them,  so  that  there  is  a  constantly  growing  irregular 
ring  of  tubercles,  either  distinct  or  confluent,  in  the  center  of 
which  is  an  area  of  smooth,  white  or  pigmented  scar  tissue 
(Fig.  35).  One  can  never  say  when  a  tubercle  will  take  on 
ulceration. 

Diagnosis. — Although  the  tubercular  syphilid  is  one  of  the 
most  strikingly  characteristic  lesions  of  the  disease,  it  may  be 
confused  with  non-ulcerative  lupus.  The  following  character- 
istics of  lupus  serve  to  differentiate  it  from  the  tubercular 
syphilid:  The  lupus  tubercle  is  smaller  and  much  more  com- 
pletely sunk  into  the  skin  than  the  syphilitic  tubercle.  It  has  a 
rather  more  yellowish  color  and  translucent  quality.  It  is  softer 
and  more  friable.  Though  not  painful,  it  is  distinctly  sensitive ; 
though  grouped,  it  is  grouped  in  an  irregular  way ;  and  its  evo- 
lution is  far  more  chronic  than  that  of  the  tubercular  syphilid. 

Treatment. — The  treatment  is  by  iodids  and  mercury. 


Fig.  36. — Pathology  of  Serpiginous  Tuberculo-ulcerative  Syphilid 
(diagrammatic),  a.  Ulcer  advancing  toward  normal  skin  (c)  and  leaving  scar 
(6)  behind  it.     d,  Outlying  perivascular  infiltration. 


3iJ 


TERTIARY    SYPHILIDS    OF    THE    SKIN 


THE    ULCERATIVE   TUBERCULAR    SYPHILID 

Under  this  general  title  may  be  included  all  pustular,  ulcer- 
ative and  crusted  tertiary  lesions  of  the  skin,  except  the  sub- 
cutaneous gumma. 

This  group  of  lesions  has  certain  common  characteristics. 


Fig.  37. — Serpiginous  Tuberculo-ulcer.\ti\'e  Syphilid.     (Fo.x.) 


THE    ULCERATIVE   TUBERCULAR   SYPHILID 


319 


TJic  individual  tubercles  arc  relatively  large.  They  begin  as 
small  tubercles,  which  soon  become  pustulous  and  then  ulcer- 
ate, all  the  while  growing  quite  rapidly. 


Fig.  38. — Serpiginous  Tuberculo-ulceeative  Syphilid.  The  sinuous  crusted 
lesion  at  the  edge  of  a  thin,  pigmented  circinate  scar  is  most  typical,  as  are  the 
circinate  scars  above  and  below  (marks  left  by  adhesive  plaster  in  middle  of 
back).     (Fordyce.) 

They  may  become  serpiginous;  that  is  to  say,  the  ulcers 
and  tubercles  creep  over  the  surface.     The  advance  may  be 


320 


TERTIARY   SYPHILIDS    OF   THE    SKIN 


centrifugal  in  all  directions  or  along  a  narrow  track  in  curves, 
inclosing  portions  of  healthy  skin ;  or  the  advance  takes  place 
in  only  one  direction,  while  the  opposite  edge  of  the  ulcer  is 
cicatrizing. 

Thus  the  serpiginous  ulcer  is  usually  a  flat  plane  of  scar 
tissue  more  or  less  completely  surrounded  by  a  ditch  of  ulcera- 
tion set  in  an  indurated  syphilid  as  a  base  (Figs.  36,  37,  38). 

The  most  important  of  the  general  characteristics  of  the 
ulcerated  syphilid  is  its  tendency  to  phagedena. 


Fig.  39. — Ancient  Serpiginous  Ulcerated  Tubercular  Syphilid  of  Brow 
Almost  Healed.  The  scar  though  very  irregular  in  general  outline  is  thin 
and  in  detail  circinate.     (Fordyce.) 


Phagedena. — Phagedena  is  a  malignant,  destructive,  rap- 
idly spreading  gangrene.      It  is  extremely  rare  except  with 


THE    ULCERATIVE   TUBERCULAR   SYPHILID 


321 


syphilis  of  the  soft  palate  (with  which  we  are  not  at  present 
concerned).  Though  a  tendency  to  phagedena  is  most  marked 
in  the  cachectic  or  in  those  whose  constitution  has  been  broken 


Fig.  40. — Phagedenic  Ulcers:  these  Malignant  Ulcerations  Appeared  in 
THE  First  Few  Months  of  the  Disease.     (Fox.) 

by  alcoholic  excess,   it  may   afflict   anyone   without   apparent 
predisposing  cause  (Fig.  39). 

Phagedena  usually  occurs  very  soon  after  the  first  appear- 
ance of  the  lesion ;  and  it  may  progress  so  rapidly  that  there 
is  practically  no  intermediate  stage  of  pustulation  or  ulcera- 
tion. The  tubercle  becomes  gangrenous,  and  immediately  the 
gangrene  spreads  like  wildfire,  devouring  the  tissues  in  its  path. 


322 


TERTIARY    SYPHILIDS    OF   THE    SKIN 


It  may  spread  chiefly  over  the  surface  (superficial  phagedena)  ; 
or  may  eat  its  way  deeply  into  the  underlying  tissues  (deep 
phagedena). 

The  course  of  phagedena  is  most  capricious.  Even  when 
untreated  its  rapid  spread  will  suddenly  stop  and  the  slough 
will  be  cast  off  and  the  lesion  go  on  to  heal ;  or,  having  stopped, 
it  may  take  a  new  start. 

Treatment. — Thus  one  can  never  be  sure  of  the  effect 
of  treatment.  When  the  gangrene  is  controlled  there  may  be 
room  for  doubt  whether  it  would  not  have  ceased  spontaneously 
quite  as  soon.  Indeed,  the  Viennese  school  attack  phagedena 
solely  by  hygiene  and  tonics,  reserving  mercury  and  the  iodids 
for  the  cure  of  the  ulcerated  lesion  left  after  the  slough  has 
been  shed. 

I  have  always  thought,  however,  that  high  doses  of  iodids 
help  to  control  phagedena,  and,  in  attacking  it,  it  has  been  my 
custom  to  push  this  drug  rapidly  to  the  point  of  saturation. 

Characteristics  of  the  Lesion. — The  ulcerative  tubercular 
syphilid  may  appear  clinically  as  a  pustular,  a  crusted,  or  an 
ulcerating  lesion.  Pustules  are  infrequent  and  rapidly  break 
to  take  on  one  of  the  other  types.  Whether  the  lesion  is  crusted 
or  ulcerated  depends  largely  upon  the  accident  of  its  situa- 
tion. Usually  it  will  be  found  covered  with  a  typical  syph- 
ilitic scab  (page  274)  ;  but  if  it  has  recently  been  picked  or 
if  it  lies  in  some  place  subjected  to  constant  friction,  the 
scab  may  be  off  and  a  typical  syphilitic  ulcer  (page  274) 
disclosed. 

Thus  the  lesion  may  appear  in  one  of  the  following  forms 
(we  give  only  the  most  important  ones,  since  they  are  useful 
merely  for  clinical  identification)  : 

Tertiary  ecthynici. 

Rupia. 

Other  forms  of  crusted  syphilids. 

The  ulcerated  syphilid. 


THE    ULCERATIVE   TUBERCULAR    SYPHILID  323 

Ecthyma. — Tertiary,  or  tubercular,  or  deep  ecthyma  dif- 
fers from  the  secondary  lesion  already  described  only  in  that  the 
pustules  are  set  upon  tubercles  instead  of  papules.  The  pustules 
are  evanescent ;  they  soon  break,  and  the  tubercle  is  covered 
with  a  thick  brownish-green  scab  set  into  and  tightly  adherent 
to  the  punched-out  ulcer.  The  lesions  are  usually  multiple  and 
small;  in  healing,  they  leave  flat,  rounded,  depressed  pits. 

RupiA. — The  rupial  syphilid  is  rare.  It  occurs  almost 
exclusively  in  debilitated  or  debauched  persons;  it  is  usually 
multiple. 


Fig.  41. — RuPlA.     (Musee,  St.  Louis.) 
23 


324 


TERTIARY   SYPHILIDS   OF   THE    SKIN 


The  ulcer  is  commonly  a  fairly  large  one  (often  an  inch 
in  diameter)  and  its  differentiating  characteristic  is  the  rupial 
scab.  The  first  crust  is  elevated  by  the  formation  of  a  layer 
of  scab  beneath  it,  and,  as  this  process  goes  on  for  weeks,  it 
becomes  finally  a  prominent,  rough,  oyster-shell  scab  marked 
by  concentric  layers  of  brownish  or  greenish  black,  projecting 
above  the  surface  almost  in  the  shape  of  a  horn.  If  the  under- 
lying ulceration  is  not  very  active,  the  scab  fits  dry  and  tight 
over  the  ulcer;  but  if  the  ulceration  is  active,  there  is  often 
an  ooze  of  pus  from  underneath  and  a  tendency  to  the  forma- 
tion of  a  bullous  ring  outside  the  crust,  due  to  the  progressive 
increase  in  the  size  of  the  ulcer  (Fig.  41). 

These  crusts  grow  to  incredible  size  before  they  finally  fall. 
The  healing  of  the  lesion  leaves  a  large,  rounded,  syphilitic 
scar.  Though  rupial  lesions  grow  gradually  in  size,  they 
almost  never  become  serpiginous. 

Treatment. — Rupia  is  one  of  the  most  obstinate  of  syphi- 
lids. Its  cure  often  depends  more  upon  tonics  and  hygiene 
than  upon  specifics,  and  in  many  cases  the  vigorous  onslaught 
with  mercury  and  iodids  so  effective  in  other  lesions  is  abso- 
lutely ineffectual.  A  much  better  plan  is  to  keep  up  a  mod- 
erate, prolonged,  specific  course  while  vigorously  attacking 
with  tonics  and  hygiene  any  manifest  deterioration  in  the 
patient's  health. 

Other  Crusted  Lesions. — The  more  common,  crusted, 
ulcerated  syphilid  does  not  form  the  mighty,  rupial  scab,  but 
tends  rather  to  spread  in  a  circinate  way  with  or  without  heal- 
ing in  the  center.  The  scabs  have  the  same  characteristics  as 
those  of  rupia,  but  do  not  grow  to  any  great  height.  The 
lesions  may  be  small,  as  in  syphilitic  ecthyma,  or  large,  round 
ulcers,  or  serpiginous  patches  (Fig.  42). 

The  Tertiary  Ulcer. — Any  of  the  lesions  just  described 
may  be  properly  classed  as  a  tertiary  ulcer  and  may  momen- 
tarily become  so  when  friction  removes  the  scab  from  the  sur- 


THE    ULCERATIVE    TUB-ERCULAR    SYPHILID 


325 


face  (Fig.  43).     The  characteristics  of  the  ulcer  have  already 
been  described  (page  274). 

Prognosis. — The  ulcerative  tubercular  syphilid  progresses 
slowly,  and  in  most  instances,  if  untreated,  shows  a  consider- 


a-— 

^^^^Hk^-^'%< 

1 

f 
i 

s 

ll 

'^^t  . 

^^K^^\^ 

■vj'  f-f  y£/  ■  ' 

:immgij^ 

Fig.  42. — Crusted  Tuberculo-ulcerative  Syphilid.  Lesions  confluent  on 
nose  and  upper  lip:  a  single  ulcerated  tubercle  is  seen  below  the  angle  of  the 
mouth.     (Fox.) 

able  tendency  to  heal  in  some  places  while  advancing  in  others. 
Indeed,  one  may  meet  old,  neglected  cases  in  which  certain 
lesions  have  healed  spontaneously,  but  even  when  this  does 
occur,  one  usually  finds  other  slowly  progressive  lesions  else- 
where on  the  skin.  Years  may  elapse  while  this  ulceration  is 
slowly  spreading,  but,  as  a  rule,  within  a  year  or  two,  if  no 
treatment  is  given,  some  other  syphilitic  lesion  appears  and 


326 


TERTIARY   SYPHILIDS   OF   THE    SKIN 


forces  the  patient  to  submit  to  treatment.  Gangrene  in  the 
form  of  phagedena  may  occur  at  the  onset  of  the  lesion,  but 
scarcely  ever  comes  on  later.  Inflammation  and  erysipelas  are 
most  exceptional  complications. 


Fig.  43. — Tertiary  Ulcer  of  Leg. 

Diagnosis. — The  diagnosis,  apart  from  the  history  and 
evidence  of  other  lesions,  is  made  from  the  appearance  of  the 
thick,  blackish  crusts ;  from  the  ulceration  itself  with  its  sharp, 
infiltrated,  punched-out  edges,  its  surrounding  dark-red  areola, 
and  its  irresrular  sloughing  or  granulating  base ;  from  the  cir- 


SUBCUTANEOUS   GUMMA  327 

cular  configuration  or  circinate  grouping  of  the  ulcers;  from 
their  insensitiveness;  and,  finally,  by  the  success  of  mixed 
treatment. 

Differential  Diagnosis. — The  differential  diagnosis  from 
ecthyma  and  lupus  has  already  been  described.  The  ulcer  of 
lupus  has  a  soft,  thin  border;  its  areola  has  a  light  color;  its 
base  is  more  raw-looking  and  more  superficial,  or  even  vegetat- 
ing, than  that  of  the  syphilitic  ulcer.  Unfortunately,  it  is  rarely 
possible  to  distinguish  the  tubercular  lesions  by  discovering 
the  bacillus,  by  inoculating  animals,  or  by  biopsy. 

Epithelioma  and  varicose  ulcers  are  much  more  closely  imi- 
tated by  subcutaneous  gumma  than  by  the  ulcerated,  tubercu- 
lar syphilid. 

Leprosy  may  usually  be  distinguished  by  the  spots  of  anes- 
thesia or  palpable  nodosities  on  the  nerves,  the  fall  of  the  eye- 
brows, the  rhinitis  and  epistaxis,  and  the  genital  and  ocular 
lesions. 

Treatment. — The  sole  local  treatment  necessary  is  to  pro- 
tect the  lesion  from  irritation  by  covering  it  with  a  thick  pad 
of  absorbent  cotton,  or,  if  it  is  ulcerated,  by  powdering  with 
calomel. 

SUBCUTANEOUS    GUMMA 

,  Subcutaneous  gumma  is  a  rather  common  lesion  most  fre- 
quent between  the  third  and  sixth  year  of  the  disease  (Four- 
nier).  Though  usually  single,  gummata  may  be  multiple,  and 
may  even  occur  in  great  numbers,  in  which  case  they  may  be 
either  grouped  or  disseminated.  Their  seat  of  election  is  the 
leg,  .but  they  may  occur  anywhere  in  the  body.  They  vary 
from  the  size  of  an  olive  up  to  that  of  a  hen's  G:g^. 

The  Pathology  of  Gumma. — The  subcutaneous  gumma 
is,  as  already  stated,  a  deep-set  syphilitic  tubercle.  At  its  onset 
it  is  simply  a  syphiloma,  a  localized  perivascular  granuloma, 
set  in  the  subcutaneous  tissue.     But  in  development  it  differs 


328  TERTIARY   SYPHILIDS   OF   THE    SKIN 

from  the  lesions  previously  described  in  that  its  center  soon 
breaks  down  into  a  gelatinous  or  gummy  mass  (whence  the 
name  "gumma").  This  central  gummy  mass  consists  of 
necrotic  tissue  held  together  by  a  network  of  fibrous  connective 
tissue,  so  that  even  when  the  necrotic  mass  is  large  and  com- 
pletely disorganized  it  does  not  become  absolutely  fluid,  but 
is  kept  in  a  characteristic  semisolid  state  by  this  network  of 
fibers. 

This  mass,  yellow  or  sero-sanguinolent  in  aspect,  rapidly 
enlarges  and  bursts  through  the  skin.  Through  the  ulcer  thus 
formed  the  gummy  center  comes  away  bit  by  bit,  leaving  a 
giUTimatous  ulcer  (Fig.  44). 

Gumma  of  the  internal  organs  (liver,  testicle,  etc.)  behaves 
somewhat  differently.  It  begins  as  a  granuloma  and  under- 
goes central  degeneration,  but  it  finds  no  outlet,  and  is  limited 
in  its  spread  by  the  change  that  occurs  in  its  own  outer  layers. 
Here  the  inflammatory  exudate  changes  gradually  into  scar 
tissue,  which  completely  envelops  the  central  gummy  mass. 
In  this  fully  developed  state  the  visceral  gumma  therefore  con- 
sists of  a  central  gummy  mass,  surrounded  by  a  dense  envelope 
of  fibrous  tissue,  which  itself  is  infiltrated  and  surrounded  by 
plasma  and  small  round  cells.  Healing  takes  place  either  by 
absorption  or  by  encapsulation  of  the  gimimy  mass.  The  con- 
traction of  the  fibrous  tissue  leaves  a  characteristic  hard,  puck- 
ered scar. 

The  diffuse  gumma  forms  still  another  pathologic  type,  in 
which  the  syphiloma  is  spread  over  a  relatively  large  area, 
undergoes  no  central  degeneration,  and  heals  by  complete 
transformation  into  scar  tissue. 

The  pathologic  diagnosis  of  full-blown  gumma  usually  pre- 
sents no  difficulty,  for  its  macroscopic  characteristics  are  quite 
typical.  Nothing  can  imitate  the  gummy  central  mass,  held 
together  by  bands  of  fibrous  tissue  and  surrounded  by  a  fibrous 
or  an  inflammatory  envelope.     The  shrunken  scar  is  almost 


SUBCUTANEOUS   GUMMA 


329 


equally  typical.  But  the  developing"  or  diffuse  gumma  may 
simulate  tuberculoma  very  closely  (it  is  not  to  be  forgotten 
that  the  tv^^o  may  coexist). 

The  features  that  distinguish  gumma  are  the  relative  promi- 
nence of  small  round  cells,  fibroblasts  and  fibrous  tissue,  the 


Fig.  44. — Gummatous  Ulcer:  Tibial  Node.     (Fordycc.) 

marked  lesions  of  the  capillary  vessels,  and  the  relative  rarity 
of  epithelioid  and  giant  cells.  If  a  necrotic  area  can  be  found 
this,  if  the  lesion  be  gumma,  will  be  gelatinous  and  adherent, 


33° 


TERTIARY   SYPHILIDS    OF    THE    SKIN 


with  a  fibrous  reticulum ;  while,  if  it  be  tubercle,  the  mass  will 
be  cheesy  or  purulent,  homogeneous,  and  readily  detachable. 
Moreover,  in  tuberculoma,  the  bacilli  can  usually  be  discerned 
by  microscope  or  by  inoculation. 

The  subcutaneous  gumma  affects  two  types,  the  single  or 
discrete  gumma  and  the  multiple  or  confluent  gumma.  These 
bear  the  same  relation  to  each  other  as  the  furuncle  and  the 
carbuncle;  the  discrete  gumma  has  a  single  center  of  syphi- 
litic infiltration,  the  confluent  gumma  has  many. 

The  Single  or  Discrete  Gumma. — The  gumma  begins 
as  an  insensitive,  little,  hard  subcutaneous  lump,  freely  movable 
over  the  subjacent  tissues,  the  integument  slightly  movable 
over  it.  In  this  condition  it  may  remain  stationary  for  months, 
but,  as  a  rule,  it  grows  slowly  (or  rapidly)  in  size,  and  within 
a  few  weeks  has  infiltrated  the  skin.-^ 

The  skin  becomes  red  and  tense,  then,  as  the  gumma  begins 
to  soften  centrally,  purple,  boggy,  and  tender  to  pressure. 
This  tenderness  is  in  marked  contrast  to  the  insensitiveness  of 
other  syphilitic  skin  lesions.  It  may  be  extreme,  and  one  must 
not  be  misled  by  it  into  supposing  the  lesion  a  simple  abscess. 

Finally,  the  softening  of  the  gumma  reaches  the  surface. 
Actual  fluctuation  may  be  determined  and  may  cover  quite  a 
large  area.  As  the  tenderness  continues,  and  may  even  be 
accompanied  by  intense  pain,  incision  is  often  practiced  to  re- 
lieve these  symptoms.  The  result  is  startling.  Instead  of  a 
gush  of  pus  there  oozes  forth  only  a  few  drops  of  bloody  or 
purulent  serum ;  the  fluctuation  persists ;  the  symptoms  are 
unabated;  the  incision  has  merely  added  a  disfiguring  scar 
to  the  list  of  the  patient's  woes ;  for,  whether  the  skin  is  broken 
by  the  surgeon's  knife  or  by  the  unchecked  progress  of  central 
caseation,  a  typical,  deep,  gummatous  ulcer  results,  whose  ori- 
fice rapidly  enlarges  until  it  covers  the  whole  mass. 

1  At  the  same  time  it  usually  becomes  adherent  to  the  subjacent  tissues. 


SUBCUTANEOUS   GUMMA  331 

The  gummatous  ulcer  has  many  of  the  characteristics  of 
the  ulcerated  tubercle.  It  is  round  or,  if  due  to  multiple,  con- 
fluent giimmata,  polycyclic  and  surrounded  by  a  dark,  indu- 
rated areola.  But  it  is  too  large  and  too  active  to  be  covered 
by  a  scab;  it  is  much  deeper  than  the  tubercular  (syphilid) 
ulcer,  and  its  base  is  occupied  wholly  or  in  part  by  the  grayish 
white,  irregular  mass  of  caseous  degeneration  which  once  was 
the  center  of  the  gumma  (Fig.  44). 

The  gumma  may  heal  at  any  stage  of  its  development,  and 
it  is  always  our  aim  to  encourage  healing  before  it  breaks,  or 
even,  if  possible,  before  it  softens.  The  rapid  development  of 
the  lesion  or  the  carelessness  of  the  patient  may  defeat  these 
efforts. 

If  healing  occurs  in  the  first  or  hard  stage,  there  will  result 
from  the  absorption  of  the  gumma  a  slightly  depressed  scar, 
though  the  skin  over  this  remains  normal.  If  healing  occurs 
in  the  second  stage,  the  stage  of  softening,  the  infiltrated  skin 
is  more  markedly  depressed  and  itself  is  more  or  less  completely 
transformed  into  scar  tissue.  If  healing  occurs  in  the  third, 
or  ulcerative,  stage,  the  ulcer  first  sheds  the  remains  of  its 
necrotic  center,  then  becomes  shallower  both  by  elevation  of 
its  center  and  by  the  flattening  down  of  its  edges.  Then  heal- 
ing takes  place  rapidly  from  the  periphery  toward  the  center, 
leaving  a  flat,  thin,  round,  depressed,  pigmented,  typical  scar 
(page  274). 

The  Confluent  Gumma. — The  confluent  gumma  begins 
with  many  adjacent  points  of  subcutaneous  syphilitic  infiltra- 
tion. These  run  together  and  progress  irregularly,  so  that, 
while  certain  parts  of  the  mass  remain  hard  and  scarcely  in- 
volve the  skin,  in  others  there  are  points  of  softening,  points 
of  ulceration,  and  even  areas  of  cicatrization  adjoining  one 
another.  The  edges  of  the  mass  may  be  quite  sharply  defined, 
or  may  shade  off  imperceptibly  into  the  surrounding  tissue. 
These  masses  of  confluent  gumma  vary  widely  in  size. 


332  TERTIARY   SYPHILIDS   OF   THE   SKIN 

Prognosis. — Subcutaneous  gumma  rarely  become  phage- 
denic, and  though  it  may  rapidly  soften  and  ulcerate,  its  fur- 
ther progress  is  often  very  slow.  For  months  and  even  years 
it  slowly  enlarges;  or  if  confluent,  progresses  in  one  direction 
while  healing  in  another,  so  that  large,  irregular  areas  of  ulcer- 
ation, induration,  and  scar  are  intermingled. 

Such  lesions  are  most  often  seen  as  chronic  leg  ulcers. 
They  may  be  treated  as  varicose  ulcers  for  years  without  ever 
getting  much  better  or  much  worse. 

The  complications  of  gumma  are  chiefly  due  to  invasion 
of  such  important  structures  as  may  lie  adjacent  to  the  growth. 
Thus  involvement  of  a  vein  may  cause  phlebitis  and  edema; 
of  an  artery,  hemorrhage;  of  a  nerve,  neuralgia  or  paralysis; 
of  a  bone,  necrosis;  of  a  muscle  or  a  joint,  mechanical  inter- 
ference with  function. 

The  coexistence  of  varicose  veins  of  the  leg  with  a  conflu- 
ent gumma  is  peculiarly  adverse  to  a  cure.  The  impaired  cir-, 
culation  greatly  interferes  with  healing. 

Diagnosis. — In  its  first  stage  the  hard,  subcutaneous 
gumma  is  scarcely  mistakable  for  anything  else,  though 
the  fact  that  it  is  a  syphilitic  product  is  often  not  suspected 
by  the  patient  or  by  his  physician  until  it  has  softened  or 
broken. 

In  the  stage  of  softening  gumma  often  resembles  abscess 
very  closely.  It  is  swollen,  red,  tender,  and  painful,  even 
fluctuating.  Yet  the  wary  observer  will  note  that  fever 
is  entirely  absent  (or  in  exceptional  cases  but  a  degree 
or  so). 

If  the  mistake  is  made  and  the  mass  incised,  the  few  drops 
of  serous  or  sero-purulent  fluid  expressed  and  the  persistence 
of  fluctuation  immediately  reveal  the  error. 

Differential  Diagnosis. — The  gummatous  ulcer  may  be 
mistaken  for  epithelioma  or  for  varicose  leg  ulcer. 

The  differentiation  between  giunma  and  epithelioma  is  not 


SUBCUTANEOUS    GUMMA 


333 


always  easy ;  for  gumma  may  be  almost  as  sluggish  as  the  true 
neoplasm,  and,  like  it,  is  very  slow  to  cause,  enlargement  of  the 
adjacent  lymphatic  nodes. 

The    ulcers    themselves    are    not    dissimilar,    though    epi- 
thelioma bleeds  more  readily  and  is  more  shallow  and  fungat- 


FiG.  45. — Multiple  Gummatous  Leg  Ulcers.  Neglect  and  filth  have  so  altered 
their  syphilitic  character  (cf.  Figs.  43,  44)  as  to  make  them  resemble  vari- 
cose ulcers  in  every  respect,  except  in  multiplicity.     (Fox.) 


ing,  while  gumma  is  more  excavated,  and  may  have  some  of 

In  some  instances  it  is 


its  sloughing  contents  in  the  base 


334 


TERTIARY   SYPHILIDS   OF   THE   SKIN 


impossible  to  make  a  diagnosis  without  examination  of  a  piece 
of  tissue  snipped  from  the  growth,  and,  as  already  stated,  J 
have  known  even  this  test  twice  to  mislead,  so  that  the  patient 
who  had  syphiloma  was  treated  surgically  and  vainly  for  epi- 
thelioma. When  this  is  done,  the  lesion  extends  until  by  its 
circinate  shape,  its  areas  of  surrounding  infiltration,  or  heal- 
ing, and  perhaps  by  a  closer  scrutiny  of  the  patient's  history, 
the  true  diagnosis  is  finally  made. 

Varicose  ulcer  is  rarely  mistaken  for  gumma,  but  old, 
gummatous  ulcers  are  very  often  treated  as  varicose  ulcers, 
especially  if  the  patient  has  varicose  veins  of  the  leg 
(Fig.  45)- 

Fournier  estimates  that  twenty  per  cent  of  chronic  leg 
ulcers  treated  as  varicose  ulcers  are  actually  syphilitic;  yet 
there  are  certain  striking,  differentiated  characteristics,  as 
shown  in  the  following  table : 


SYPHILITIC    LEG    ULCER 

1.  Situation.  —  Anywhere. 

Often  in  calf  or  in  upper 
half  of  leg. 

2.  Number.  —  Often  multiple. 

3.  Shape. — Round     or    poly- 

cyclic. 

4.  Edges. — Sharp,     deep,     or 

even  undermined, 

5.  Surrounding      Tissues.  — 

Very  slight  areola,  un- 
less there  be  old  scars  or 
other  foci  of  syphilitic 
infiltration. 

6.  Base.  —  Granulating 

sloughing. 


VARICOSE    LEG    ULCER 

1.  Only  in  lower  third  of  leg. 

Habitually    on    internal 
surface. 

2.  Very  rarely  multiple. 

3.  Irregular. 

4.  Rounded,     shallow,     never 

undermined. 

5.  Extensively     and     irregu- 

larly   pigmented,    thick- 
ened, and  adherent. 


or    6.  No  special  type. 


SUBCUTANEOUS    GUMMA  335 

SYPHILITIC    LEG    ULCER  VARICOSE    LEG    ULCER 

7.  Other  Evidences  of  Syphi-     7.  No. 

Us. — The  history  is  fre- 
quently defective.  There 
are  often  scars  elsewhere 
on  the  body. 

8.  Varicose    Veins. — May   be     8.  Constant. 

present. 

9.  Mixed  Treatment. — Cures.     9.   Ineffectual. 

Treatment. — The  general  treatment  of  gumma  is  by  mixed 
treatment,  with  especial  insistence  on  iodids.  They  may  not 
have  to  be  given  in  very  high  dose,  but  they  are  practically 
always  necessary  to  cure  the  lesion,  while  mercury  is  useful 
as  an  adjuvant  and  necessary  to  prevent  relapse. 

The  local  treatment  is  almost  nil.  In  the  hard  stage,  mer- 
curial ointment  or  plaster  may  be  applied.  In  the  soft  stage, 
the  part  should  be  protected  from  trauma  and  kept  at  rest; 
hut  must  not  be  incised  under  any  circumstances,  no  matter 
how  fluctuating  or  how  tender  it  may  be. 

After  the  gumma  has  opened,  its  healing  may  be  hastened 
by  ordinary  surgical  cleanliness ;  gently  removing  sloughs,  and 
keeping  the  ulcer  bathed  in  a  mild  ( i  :  5,000)  solution  of 
bichlorid  if  it  is  inflamed;  applying  mercurial  ointment  or  plas- 
ter if  it  is  chronic  and  sluggish.  For  syphilitic  leg  ulcer  com- 
plicated by  varicose  veins,  rest  in  bed  is  often  essential  in  order 
to  encourage  the  circulation. 

Generally  speaking,  however,  the  less  done  to  the  ulcer 
beyond  keeping  it  surgically  clean,  the  quicker  it  will  heal. 

Scars  left  by  syphilitic  ulcers  may  demand  a  plastic  oper- 
ation, but  this  should  not  be  performed  until  all  active  syphilis 
has  ceased  for  several  months. 


CHAPTER    XXIII 1 

SECONDARY  SYPHILIS  OF   THE  MUCOUS  MEMBRANES 

t 

The  early  secondary  lesions  of  the  mucous  membrane  are 
usually  spoken  of  as  mucous  patches  or  mucous  plaques.  But, 
inasmuch  as  these  lesions  are  certainly  not  patches  and  very 
rarely  plaques,  it  is  more  proper  to  classify  them  under  their 
true  names  of  mucous  papules  and  iilcers. 

Distribution. — They  may  affect  any  part  of  the  mucous 
membranes  and  also  any  part  of  the  skin  which  in  texture  and 
moisture  simulates  the  physical  conditions  of  mucous  mem- 
brane. They  are  commonest  in  the  mouth  and  throat  and  in 
and  about  the  genitals. 

These  are  among  the  most  important  lesions  of  syphilis; 
for,  although  less  common  in  the  woman  who  does  not  smoke 
than  in  the  man  who  does,  they  are  generally  among  the  earli- 
est, the  most  numerous,  and  the  most  constantly  relapsing 
lesions  of  the  disease.  Moreover,  they  are  often  painless,  so 
that  the  patient  may  have  a  mouthful  or  a  vaginaful  of  them 
without  knowing  they  are  there,  and,  finally,  they  are  by  far 
the  most  infectious  secondary  lesions. 

One  marvels  that  so  keen  an  observer  as  Ricord  should 
have  denied  that  these  secondary  lesions  are  infectious;  for 
certainly  they  inoculate  far  more  victims  than  do  the  primary 
lesions. 

Etiology. — Local  irritation  is  the  exciting  cause.  In  the 
mouth   the   local    irritation    of   tobacco,    whether   smoked   or 


*  Reviewed  by  Dr.  L.  M.  Hurd. 
336 


THE    EROSIVE   OR   PAPULAR    SYPHILID  337 

chewed,  stands  preeminent.  About  the  folds  of  the  skin  un- 
cleanHness  excites  them.  In  the  male  they  are  more  common 
in  the  mouth  than  elsewhere ;  in  the  female,  much  more  com- 
mon about  the  genitals  on  account  of  the  profuse  secretions 
there. 

Classification. — The  secondary  syphilids  of  the  mucous 
membranes  may  be  classified  as  follows : 

1.  Macular  syphilid. 

2.  Erosive  or  papulo-erosive  syphilid   (mucous  papule). 

3.  Ulcerative  syphilid. 

4.  Squamous  syphilid. 

Of  these  the  macular  syphilid  is  unimportant.  The  ero- 
sive papular  and  ulcerative  types  are  common  in  the  first  year 
of  the  disease  and  occur  infrequently  for  several  years  there- 
after, while  the  squamous  types  are  rarely  seen  before  the 
second  or  third  year,  and  may  continue  indefinitely  thereafter. 

THE    MACULAR    SYPHILID 

Roseola  of  the  mouth  is  not  recognized  by  Fournier;  but 
laryngologists  recognize  a  diffuse  symmetrical  erythema  of 
the  velum  and  the  anterior  pillars  of  the  fauces  that  persists 
for  some  weeks  and  is  almost  always  present  at  the  time  the 
first  mucous  papules  appear  in  the  mouth. 

THE    EROSIVE    OR    PAPULAR    SYPHILID 

The  syphilitic  papule  upon  a  moist  skin  or  mucous-mem- 
brane surface  is  always  eroded.  Even  upon  a  dry  surface  it 
sheds  the  superficial  epithelium,  and,  when  kept  moist,  the 
deeper  layers  are  more  freely  exposed  and  exudation  from 
the  surface  of  the  papule  is  thus  a  constant  phenomenon  in 
all  papular  lesions  of  mucous  or  moist  surfaces.  (In  the  later 
syphilids   the  growth   of  the  papule   is  slow   and   is   usually 


338   SECONDARY   SYPHILIS   OF   THE    MUCOUS   MEMBRANES 

accompanied  by  an  epithelial  thickening  rather  than  a  thin- 
ning; hence  it  assumes  a  distinctive  squamous  type.) 

The  early  erosive  papular  lesion  may  be  so  slight  as  to 
produce  no  perceptible  irregularity  in  the  surface.  Its  top  is 
level  with  the  surrounding  mucous  membrane,  but  it  is  an 
eroded  top,  and,  consequently,  the  papule  appears  as  a  simple 
erosion.  In  a  second  type  the  papule  is  elevated  above  the 
surface  to  a  slight  degree  and  becomes  a  typical,  eroded  papule, 
while  in  the  third  type  it  is  hypertrophic  and  becomes  a  vege- 
tating papule  or  condyloma.  Hence  the  three  types  of  erosive 
papular  syphilids : 

The  erosion. 

The  eroded  papule. 

The  vegetating  papule  or  condyloma. 

The  Erosion. — The  syphilitic  erosion  is  the  least  charac- 
teristic of  the  lesions  of  syphilis.  It  may  occur  on  any  moist 
surface;  it  may  appear  and  disappear  within  a  day  or  two,  or 
persist  for  several  days.  It  is  sometimes  sensitive  or  painful ; 
oftener  not.  It  consists  simply  in  an  oozing  surface  bereft  of 
its  normal  epithelial  covering.  This  surface  may  be  only  a 
little  redder  than  the  surrounding  tissues,  or  it  may  be  grayish 
and  opalescent,  or  it  may  be  covered  with  a  yellowish  false 
membrane  from  mixed  infection.  It  varies  from  the  size  of 
the  head  of  a  pin  to  that  of  a  split  pea,  or  occasionally  larger. 
Its  shape  is  usually  rounded,  but  may  be  quite  irregular.  The 
confluence  of  several  lesions  may  form  a  polycyclic  lesion. 

Given  a  single  lesion  or  group  of  lesions  of  this  character 
about  the  mouth  or  genitals  and  we  may  be  completely  at  a 
loss  to  diagnose  their  nature.  The  lightest  cauterization  cures 
them. 

The  Eroded  Papule. — The  eroded  papule  is  one  of  the 
most  characteristic  lesions  of  the  disease.  It  is  but  slightly 
elevated  above  the  surrounding  surface.  Its  top  is  flat  or  very 
slightly  convex.     In  size  it  averages  larger  than  the  erosion 


THE    EROSIVE    OR   PAPULAR   SYPHILID 


339 


(it  may  even  be  larger  than  a  ten-cent  piece).  It  is  strictly 
circular  in  shape.  Its  surface  is  eroded  and  moist;  sometimes 
smooth,  but  oftener  slightly  roughened.  It  is  rather  dark  red 
in  color,  rarely  grayish  or  covered  with  a  false  membrane. 
The  eruption  may  be  confluent  and  polycyclic.  There  may 
be  a  slight  tendency  to  vegetation,  in  v^^hich  case  the  surface  of 
the  papule  are  broken  into  little  warty  projections.  The 
eroded  papule  is  usually  quite  soft,  though  about  the  genitals 
— especially  about  the  vulva  or  the  preputial  frenum — the  base 


Fig.  46. — Pathology  of  Condyloma.  (Diagrammatic.)  a,  desquamating  epi- 
thelium, b,  greatly  hypertrophied  and  infiltrated  papilla  of  derma,  c,  tip 
of  papilla  in  cross-section. 


may  be  slightly  indurated  (the  indurated  chancriform  syphilid 
of  Fournier). 

The  exudation  from  the  surface  of  the  papule  is  serous, 
irritating,  and  foul-smelling.    The  peculiar  acrid  odor  (though 
scarcely  pathognomonic)    is  very  suggestive  and  very  pene- 
trating.    The  exudation  from  the  lesion  irritates  the  surround- 
24 


340  SECONDARY   SYPHILIS   OF   THE   MUCOUS   MEMBRANES 

ing  tissues  and  even  irritates  the  lesion  itself,  causing  the 
tendency  to  vegetation  so  noticeable  when  the  erosive  papule 
occurs  upon  the  skin. 

The  Vegetating  Papule  or  Condyloma. — The  eroded  pap- 
ule upon  the  skin  or  about  the  orifices  of  the  anus  or  the 


Fig.  47. — Macular  Syphilid  and  Condylomata.     (Fox.) 


vagina,  if  permitted  to  bathe  in  its  own  secretions,  rapidly 
hypertrophies.  The  infiltrated  papillae  of  the  skin,  instead  of 
remaining   distorted   and   slightly   swollen,    as    in   the  typical 


THE    EROSIVE    OR    PAPULAR   SYPHILID 


341 


syphilitic  papule,  grow  and  branch  out  into  numerous  irregu- 
larly shaped  fingers,  while  the  deeper  layers  of  epithelium  sur- 


FiG.  48. — Condylomata  About  the  Anus.  (Fox.) 

rounding  them  are  much  thickened  by  swelling  of  their  cells 
(Fig.  46). 

These  hypertrophic  papules  usually  occur  in  groups  form- 
ing irregular  masses,  which  may  cover  an  area  two  or  three 
inches  in  diameter  and  may  rise  half  an  inch  or  more  above 
the  surface.  The  striking  characteristic  of  this  lesion  is  that, 
though  a  vegetating  one,  the  vegetation  is  relatively  low  com- 
pared to  the  extent  of  the  base ;  hence  it  is  commonly  known 


342   SECONDARY   SYPHILIS   OF   THE   MUCOUS   MEMBRANES 

as  condyloma  latum.  Its  foul  secretion,  its  irregular,  broken, 
vegetating,  and  eroded  red  surface  constitute  amplifications  of 
the  characteristics  of  the  eroded  papule  (Figs.  47,  48). 


THE    ULCERATIVE    SYPHILID 

Just  as  the  papule  may  appear  as  a  simple  erosion,  an 
irritated  papule,  or  a  hypertrophied  papule,  so  the  ulcer  may 
appear  as  a  simple  ulcer,  as  an  ulcerated  papule,  or  as  an 
ulcerated  hypertrophied  papule. 

The  Simple  Ulcer. — The  characteristics  of  the  ulcer,  like 
those  of  the  erosion,  are  not  very  typical.  The  ulcers  may 
be  superficial  or  deep,  simple  or  multiple,  discrete  or  confluent, 
rounded  or  polycyclic. 

Superficial  ulcers  are  little  more  than  deep  erosions  and 
have  the  same  characteristics.  The  deeper  ulcers  are  slow- 
growing,  and,  in  the  mouth,  usually  collect  about  the  tonsils 
and  fauces.  Their  edges  are  raised,  sharply  cut;  their  bases 
snrooth,  unindurated,  and  red  or  yellow.  They  look  a  great 
deal  like  chancroid,  and  exude  true  pus.  Exceptionally  they 
are  irregular  in  shape  and  have  no  distinguishing  character- 
istics. When  occurring  at  the  angle  of  the  mouth,  or  at  any 
other  fold,  they  are  likely  to  be  deeply  fissured. 

The  Ulcerated  Papule  and  the  Ulcerated  Condyloma. — 
Superficial  or  deep  ulceration  may  occur  upon  an  eroded 
papule  or  upon  a  syphilitic  condyloma.  Such  ulcerations  have 
no  very  special  characteristics. 

THE    SQUAMOUS   SYPHILID 

The  squamous  syphilid  of  the  mucous  membranes  (syphi- 
litic leukoplakia,  tylosis,  milk  patch,  pearly  patch),  though  a 
secondary  manifestation,  is  closely  allied  to  certain  more  im- 
portant tertiary  manifestations.     It  is  secondary  in  that  it  is 


DIAGNOSIS  343 

curable,  like  other  secondary  mucous-membrane  lesions,  by 
mild  cauterization  and  mercury,  and  in  healing  leaves  no  scar. 
Yet  it  is  most  commonly  seen  late  in  the  disease  upon  the 
tongue,  where  it  assumes  the  position  of  the  most  superficial 
form  of  tertiary  sclerosis.  It  may  seem  contradictory  to  speak 
of  a  secondary  form  of  a  tertiary  lesion;  but  this  may  serve 
to  impress  the  fact  that  the  division  of  the  lesions  of  syphilis 
into  secondary  and  tertiary  is  purely  clinical  and  arbitrary. 
We  assume  the  general  distinction  for  the  sake  of  convenience, 
and,  in  this  instance,  v^e  dismiss  it — for  the  same  reason. 

The  secondary  squamous  syphilid  will,  accordingly,  be  de- 
scribed with  tertiary  sclerosis  of  the  tongue. 

DIAGNOSIS 

Erosion  and  Ulceration  in  the  Mouth. — While  the  flat, 
erosive  papule  of  syphilis  is  usually  quite  characteristic,  the 
erosion,  the  ulcer,  and  even  the  ulcerated  papule,  may  be  in- 
distinguishable from  certain  non-specific  lesions.  The  most 
important  lesion  to  be  differentiated  is  the  ulceration  due  to 
mercurial  stomatitis. 

Mercurial  ulceration  may  follow  close  upon  the  syphilitic 
ulceration  for  which  the  mercury  is  given.  I  have  known 
patients  to  go  through  this  transition  quite  unconsciously,  and 
since,  with  additional  mercury,  the  ulceration  progressively 
increases,  they  rapidly  reach  a  fine  state  of  salivation. 

I  know  no  pathognomonic  characteristic  to  distinguish  the 
ulcer  of  syphilis  from  that  of  mercury,  but  the  latter  rarely 
occurs  upon  the  fauces  or  upon  the  dorsum  of  the  tongue  or 
in  the  angle  of  the  lips,  where  syphilitic  ulcers  are  common; 
while  it  is  almost  typical  of  mercurial  ulceration  to  find  a  lesion 
on  the  cheek  or  gum  hack  of  the  last  molar  tooth,  or  about 
the  upper  or  lozuer  central  incisors. 

The  ulceration  back  of  the  molars  is  usually  quite  large. 


344     SECONDARY   SYPHILIS   OF   THE   MUCOUS   MEMBRANES 

deep,  and  painful.  That  about  the  incisors  is  associated  with 
retraction  of  the  gum,  and  other  ulcers  may  be  found  wherever 
there  is  a  broken  or  an  irregular  tooth. 

Confirmatory  evidence  may  be  looked  for  in  the  presence 
or  absence  of  the  usual  signs  of  salivation;  yet  there  may  be 
mercurial  ulcers  with  very  slight  general  salivation.  The  only 
way  to  prove  the  nature  of  the  lesion  is  to  stop  the  mercury 
and  redouble  the  efforts  at  cleansing  the  mouth  (page  163). 
All  cauterization  should  be  eschewed  and  one  should  await 
developments.  If  the  ulcers  are  due  to  mercury  they  wall  soon 
disappear,  unless  the  patient  has  been  severely  salivated;  if 
due  to  syphilis  they  will  multiply.  Unfortunately,  since  mer- 
cury decimates  the  spirochetae,  microscopical  examination  of 
a  smear  is  futile. 

Aphthous  erosions  are  very  common  in  syphilis  and  accu- 
rately simulate  syphilitic  ulcers  of  the  mouth,  except  that  the 
aphthous  spots  are  usually  intensely  irritable  and  quite  pain- 
ful, whereas  the  small  superficial  syphilitic  ulcer  is  usually, 
.  though  not  always,  relatively  painless.  Aphthae  always  re- 
main very  small. 

Herpes  of  the  mouth  is  also  quite  frequent.  It  begins  as 
a  single,  little  opalescent  papule  or  a  group  of  such  papules. 
It  rapidly  becomes  eroded  and  its  surface  whitish.  Finally, 
all  the  epithelium  falls,  and  it  remains  a  reddish,  little,  round, 
superficial  erosion.  Its  distinguishing  characteristics — in  con- 
trast to  the  syphilitic  erosion — are  the  smallness  of  the  single 
lesions,  the  frequency  of  a  group  of  lesions,  the  polycyclic  and 
microcyclic  character  of  the  confluent  lesions   (page  245). 

Fournier  attaches  great  clinical  importance  to  this  last 
characteristic.  He  also  states  that,  at  any  stage  of  the  erup- 
tion, one  is  likely  to  find  isolated  miliary  erosions  no  larger 
than  the  head  of  a  pin  in  the  neighborhood,  and  that  if  the 
eroded  lesion  is  surrounded  by  a  collarette  of  whitish  epithel- 
ium, it  is  not  syphilitic. 


DIAGNOSIS  345 

Besides  the  common  lesions  of  aphthous  stomatitis  and 
herpes,  many  other  rarer  conditions  simulate  the  ulcerative 
or  erosive  syphilid  of  the  mouth.  Thrush,  diphtheria,  and 
hydroa  may  produce  similar  lesions,  while  simple  erosions  due 
to  burns,  etc.,  may  be  quite  indistinguishable  from  syphilis. 

The  differential  diagnosis  of  any  of  these  lesions  must 
often  be  left  to  time,  and  the  ablest  diagnostician  will  confess 
that,  in  many  instances,  a  number  of  lesions  have  come  and 
gone  before  he  was  able  to  state  definitely  that  they  were  or 
were  not  syphilitic. 

Erosion  and  Ulceration  within  the  Female  Genitals. — 
Simple  erosions  due  to  endometritis  may  appear  on  the  cervix 
or  elsewhere  within  the  genital  passages,  and,  for  a  time,  at 
least,  simulate  syphilitic  erosions ;  but,  like  erosions  of  simple 
balanitis,  they  are  changeable,  fugitive,  and  readily  cured. 

Chancroid  about  the  orifice  of  the  female  genitalia  may 
suggest  syphilitic  ulceration.  It  should  be  distinguished  by 
autoinoculation. 

Mucous  Papules  of  the  Skin  of  the  Genitals  and  Else- 
where.— The  soft,  flat,  eroded  papule  can  scarcely  be  mistaken 
for  any  other  lesion  unless  it  has  been  partly  healed  by  the 
application  of  a  drying  powder.  In  this  semihealed  state  it 
may  simulate  the  papules  of  scabies,  but  is  distinguishable 
from  them  by  the  absence  of  itching. 

Condylomata  Lata. — The  fungating  syphilid  may,  in 
some  degree,  resemble  so-called  venereal  warts,  or  condylo- 
mata acuminata ;  but  the  titles  of  the  two  lesions  suggest  their 
striking  difference. 

The  simple  wart  is  sharp  and  projects  relatively  high  from 
a  small  base,  while  the  syphilitic  wart  has  a  broad  implanta- 
tion and  a  relatively  slight  elevation.  The  application  of  any 
simple  dusting  powder  to  the  syphilitic  condylomata  will  rap- 
idly shrivel  them  and  effect  a  cure  while  establishing  the 
diagnosis. 


346   SECONDARY    SYPHILIS    OF   THE    MUCOUS    MEMBRANES 

TREATMENT 

The  general  treatment  of  all  these  lesions  consists  in  the 
administration  of  mercury.  But,  inasmuch  as  the  marked 
tendency  to  relapse  is  due  to  local  causes,  the  cure  is  the  re- 
moval of  these  local  causes  and  local  treatment,  rather  than 
vigorous,  general  antisyphilitic  treatment. 

Indeed,  one  often  sees  cases  in  which  mercury  and  iodids 
have  been  vainly  pushed  to  the  limit  of  toleration  promptly 
recover  under  mild  mercurial  treatment  aided  by  appropriate 
local  measures.  The  local  treatment,  therefore,  is  much  the 
more  important. 

Local  Treatment  of  Lesions  upon  the  Skin. — If  the 
lesion  is  upon  the  skin  it  is  usually  possible  to  keep  it  dry,  and 
this  drying  will  cure  erosion  or  vegetation  as  if  by  magic.  In 
mild  cases  all  that  is  necessary  is  to  cleanse  the  affected  region 
thoroughly  twice  a  day  with  warm  soap  and  water,  .then  dry 
and  apply  pure  calomel  or  calomel  mixed  in  equal  parts  of 
stearate  of  zinc  or  talcum. 

For  extensive  condylomata  it  may  be  necessary  to  paint 
with  a  solution  of  permanganate  of  potash  (i:  i,ooo)  twice 
a  day  and  to  interpose  a  layer  of  absorbent  gauze  between  the 
various  inflamed  surfaces  after  powdering  the  whole  region 
thickly. 

For  subpreputial  erosions  when  inflammatory  phimosis 
prevents  retraction  of  the  prepuce,  one  may  inject,  twice  a 
day,  a  four  per  cent  resorcin  solution,  or  a  i  :  2,000  perman- 
ganate-of-potash  solution.  If  this  does  not  speedily  cure,  cir- 
cumcision should  be  performed. 

For  ulcers,  cauterization  twice  a  week  with  the  nitrate-of- 
silver  stick  is  an  important  accessory. 

Local  Treatment  of  Lesions  within  the  Mouth. — 
It  is  impossible  to  keep  these  lesions  dry,  hence  they  are  often 
more  difficult  to  manage  than  the  external  lesions. 


SECONDARY    SYPHILIDS    OF    THE    EAR 


347 


The  most  important  point  in  local  treatment  is  mild  cau- 
terization, and  the  best  cauterizing-  agent  is  the  officinal  liquor 
hydrargyri  nitratis,  either  pure  or  diluted  to  one  half  or  one 
quarter  strength.  The  pure  fluid  can  be  applied  only  to  small 
lesions,  as  it  is  quite  painful.  TJiis  application  should  he  made 
not  of  teller  than  tztnce  a  zveek,  and  should  never  be  confided 
to  the  hands  of  the  patient,  since  overcauterization  makes  the 
lesion  worse  instead  of  better. 

The  nitrate-of-silver  stick  often  acts  quite  as  well  as  the 
acid  nitrate  of  mercury,  and  like  it  may  be  applied  twice 
a  week. 

Crystals  of  copper  sulphate  may  be  applied  to  the  lesion 
by  the  patient  himself,  and  may  often  be  used  with  advantage 
every  other  day,  but  are  not  nearly  so  effective  as  the  mercury 
or  silver. 

In  order  to  prevent  relapses  of  secondary  syphilids  within 
the  mouth,  it  is  often  necessary  for  the  patient — 

To  stop  smoking  and  chewing  tobacco; 

To  keep  the  teeth  and  gums  in  perfect  condition; 

To  employ  twice  daily  an  antiseptic  mouth  wash  (page 
163). 

SECONDARY    SYPHILIDS    OF    THE    EAR 

The  lesions  of  secondary  syphilis  in  and  about  the  ear  are 
both  rare  and  unimportant. 

In  the  external  auditory  canal  mucous  papules  and  condy- 
lomata may  occur.  Careful  examination  readily  distinguishes 
the  latter  from  sessile  polypi. 

The  treatment  is  by  drying  powders. 

In  the  Eustachian  tube  mucous  papules  (usually  extending 
from  similar  lesions  in  the  naso-pharynx)  may  cause  obstruc- . 
tion,  resulting  in — 

I.  Partial  deafness,  buzzing  in  the  ear,  and  sometimes 
vertigo;  and 


348   SECONDARY   SYPHILIS   OF   THE    MUCOUS   MEMBRANES 

2.  Acute  otitis  media  from  mixed  infection  due  to  the 
obstruction.     (I  have  record  of  two  such  cases.) 

The  treatment  consists  of  douches  to  the  nose,  while  mer- 
curial treatment  is  pushed  and  hot  douches  applied  to  prevent 
otitis  (or  myringotomy  to  cure  it).  No  attempt  should  be 
made  at  dilatation,  catheterization,  or  Politzerization  of  the 
canal. 

In  the  inner  ear  secondary  and  tertiary  lesions  are  clin- 
ically indistinguishable  (page  367). 


CHAPTER    XXIV  1 

TERTIARY  SYPHILIS  OF  MOUTH,  PHARYNX,  NOSE 
AND   EAR 

In  this  chapter  are  collected  a  great  variety  of  lesions 
connected  only  by  an  anatomical  relation.  Clinical  conve- 
nience bids  us  throw  them  together.  They  are  the  tertiary 
lesions : 

1.  Of  the  lips. 

2.  Of  the  tongue,  including  leukoplakia. 

3.  Of  the  tonsil. 

4.  Of  the  soft  parts  of  the  pharynx. 

5.  Of  the  soft  palate  (velum). 

6.  Of  the  hard  palate. 

7.  Of  the  nose. 

8.  Of  the  ear. 

Occurrence. — The  table  on  next  page  shows  the  frequency 
and  date  of  occurrence  of  these  lesions  (excepting  the  lips 
and  ears).  The  last  column  sums  up  the  gummatous  and 
ulcerative  lesions  for  contrast  with  the  purely  sclerotic 
lesions  in  the  first  column.  The  only  striking  difference 
thus  shown  is  that  the  former  are  relatively  much  more 
frequent  than  the  latter  in  the  first  two  years  and  after 
the  fifteenth  year  of  the  disease.  The  occurrence  of  each 
class  becomes  about  fifty  per  cent  less  frequent  with  each  half 
decade. 

1  Reviewed  by  Dr.  L.  M.  Hurd. 

349 


350 


TERTIARY    SYPHILIS    OF    MOUTH,    PHARYNX,    ETC. 


Onset  of  Tertiaries  about  the  Mouth  and  Naso- 
pharynx 


Year 

Tongue 
Leuko- 
plakia 
and 
Sclero- 
sis 

Tongue 
Gum- 
ma and 
Ulcer 

Tongue 

Sclero- 

Gum- 

ma 

Pha- 
rynx 

Nasal 
Septum 

Tonsil 

Velum 

Palate 

Total 
Gum- 
mata 

I 

2 

3--- 

4 

5 

6 

7 

8 

2 

14 
20 

19 
II 
12 

9 
2 
2 

7 
4 
2 

3 
3 
2 

3 

2 

12 

4 

4 
4 

2 

I 
I 
I 

3 

I 
I 

2 

5 
4 
8 

4 

I 

4 

5 

I 

I 
6 
6 
5 
3 
7 
3 
I 

3 

2 

I 
I 

3 
7 
2 
2 

3 

4 
2 

5 
3 
4 
2 

I 
2 

I 

3 
4 

2 

I 

I 

3 

I 
I 
I 
2 

21 

27 

25 
20 
II 
19 
13 
6 

9 

lO 

I 
I 

I 

2 

I 

6 

3 
3 

2 

3 

I 

2 

I 
7 

5 

II 

12 

13 

14 

15-19 

20-24 

26-41 

Indefinite. . 

I 

2 

9 
9 
4 

I 
2 
2 

I 
2 

I 

I 
I 

I 
I 

4 

4 

2 

12 
6 

3 
10 

4 

^       i 

5 

7 

30 

Total... 

129 

24 

13 

54     ^     56     ■     27 

29 

28 

231 

Influence  of  Tobacco. — The  influence  of  tobacco  in  ex- 
citing leukoplakia  and  sclerosis  is  great,  while  it  excites  (ter- 
tiary) ulceration  much  less  and  gumma  not  at  all.  The  most 
Striking  evidence  of  this  is  the  fact  that  only  two  cases  of 
leukoplakia  are  recorded  among  women,  while  of  the  gum- 
matous and  ulcerative  lesions,  31  (tongue,  4;  pharynx,  7; 
septum,  8 ;  tonsil,  3 ;  velum,  6 ;  and  palate,  4)  occurred  in 
women. 

Relapses. — Though  leukoplakia  is  hard  to  cure  and  may 
defy  treatment  for  many  years,  only  four  relapses  are  recorded 
(six  to  seven  to  nine  to  twelve  years,  four  to  six  years,  four 
to  twelve  years,  six  to  fifteen  years)  in  cases  cured  and  remain- 
ing well  one  year. 


TERTIARY   LESIONS   OF   THE    LIPS  351 

Gummata,  though  readily  curable,  show  relapses  in  tongue 
(four  to  six  years,  twelve  to  seventeen  years,  sixteen  to  eight- 
een years),  pharynx  (two  to  six  years,  four  to  five  to  eight 
years,  eleven  to  thirteen  years),  and  tonsil  (two  to  four  years, 
seven  to  nine  years).  No  relapses  are  recorded  in  cured  gum- 
mata of  velum;  palate  and  septum  show  one  each  (one  to  four 
years  and  two  to  six  years,  respectively). 

Concurrence  of  Lesions. — The  relative  frequency  of  si- 
multaneous or  successive  outbreaks  in  two  or  more  of  the 
regions  under  discussion  is  not  great.  The  360  lesions  ^ 
occurred  in  321  patients,  there  being  36  duplications  and  two 
triplications  (velum-tonsil-pharynx  and  velum-palate-septum). 

This  concurrence  is  usually  due  to  direct  extension  of  a 
phagedenic  lesion  from  one  tissue  to  an  adjoining  one,  but 
sometimes  to  what  might  be  termed  a  "  regional  "  tendency 
in  the  outbreak.  The  case  already  related  ^  (page  20)  is  an 
excellent  example  of  this.  The  tongue  gumma  and  the  ne- 
crosis of  the  mandible  were  regionally,  but  not  directly,  con- 
nected with  the  tonsil-velum  lesions. 

These  concurrences  are  separable  into  three  classes : 

Sclero-gumma  of  tongue — 13  cases. 

Leukoplakia  and  lesions  of  tonsil  or  pharynx — 9  cases. 

Septum  and  palate  or  velum — 7  cases. 

TERTIARY   LESIONS   OF   THE   LIPS 

The  striking  characteristics  of  diffuse,  tubercular  syphilitic 
infiltration  about  the  lips  and  nose  have  already  been  men- 
tioned (page  312).  The  distinction  between  gumma  and 
chancre  of  the  lip  has  been  dwelt  upon  (page  249),  and  an 
instance  of  phagedena  in  lip  chancre  cited  (page  231). 

Finally,  there  may  be  added  to  the  other  diffuse  infiltra- 

•  Excluding  recurrences. 

2  Not  included  in  these  statistics. 


352      TERTIARY   SYPHILIS   OF   MOUTH,    PHARYNX,    ETC. 

tions  grouped  under  the  head  of  "  leontiasis,"  a  thickening  of 
the  lips  without  a  tendency  to  gummatous  degeneration  and 
without  surface  lesions,  though  it  may  be  accompanied  by 
them.  This  process  is  a  diffuse,  interstitial  sclerosis.  The 
lips  look  as  though  enlarged  by  edema,  but,  though  they  yield 
to  pressure,  they  do  not  pit.  The  condition  is  often  associated 
with  sclerotic  Sflossitis. 


TERTIARY    LESIONS    OF    THE    TONGUE 

Tertiary  syphilis  of  the  tongue  appears  under  two  forms, 
the  sclerotic  and  the  gummatous.  Inasmuch,  however,  as 
sclerosis  of  the  tongue  is  closely  allied  to  the  secondary,  super- 
ficial squamous  syphilid  of  the  tongue,  this  will  be  included. 
Accordingly,  the  lesions  to  be  discussed  are  leukoplakia,  inter- 
stitial glossitis,  and  gumma. 

LEUKOPLAKIA 

By  leukoplakia  (tylosis,  milk  spot,  etc.)  is  meant  a  chronic 
inflammation  of  the  mucous  membrane  characterized  by  the 
appearance  of  pearly  white  or-  bluish  white  patches.  These 
patches  may  appear  anywhere  inside  the  mouth,  but,  while 
extremely  common  upon  the  tongue,  they  are  very  rare  else- 
where. I  have  record  of  only  seven  cases  occurring  on  the 
mucous  membrane  of  the  cheeks,  and  I  have  recently  seen  one 
case  in  which  the  change  was  entirely  confined  to  the  gums ; 
but  it  is  seen  most  constantly  and  typically  upon  the  tongue. 

Etiology. — It  is  still  a  matter  of  dispute  what  proportion 
of  cases  of  leukoplakia  are  due  to  syphilis.^  Of  late  years  we 
have  appreciated  more  and  more  how  important  a  factor 
syphilis  is;  for  leukoplakia  of  the  mouth,  like  the  squamous 

1  Cf.    Marshall,    Treatment,    1906,    January;    also    Chichkoff,    These  de 
Paris,  1902. 


PLATE    IX. 


PLATE   IX. — Tertiary  Lesions  of  the  Tongue. 

Fig.  I. — Interstitial  glossitis.     (Musee,  St.  Louis.) 

Fig.  2. — Leukoplakia  (superficial  glossitis).     (Musee,  St.  Louis.) 

Fig.  3. — Gumma  of  the  tongue.     (Musee,  St.  Louis.) 

Fig.  4. — Superficial  tertiar}'  (gummatous)  ulcer  of  the  tongue.     (Musee,  St.  Louis.) 


LEUKOPLAKIA  353 

syphilid  of  the  palm,  is  very  rebellious  to  specific  treatment, 
and  it  is  only  since  the  introduction  of  the  injection  method 
that  the  majority  of  these  cases  have  been  proven  curable  by 
mercury,  and  therefore  shown  themselves  to  be  syphilitic. 

But  if  most  are  syphilitic,  a  certain  few  surely  are  not; 
and,  while  it  may  be  impossible  in  a  given  case  to  say  before- 
hand whether  or  not  the  leukoplakia  is  due  to  syphilis,  one 
encounters  certain  cases  in  which  all  history  of  syphilis  is 
denied,  in  which  no  antisyphilitic  treatment  has  any  curative 
effect,  and  in  which  the  lesion  itself  has  a  slightly  elevated 
and  papillomatous  character,  not  in  the  least  suggestive  of 
syphilis.  Indeed,  I  have  seen  one  case  in  which  leukoplakia 
preceded  the  chancre  and  continued  throughout  the  syphilis 
that  followed. 

Smoking  is  the  real  exciting  cause.  Leukoplakia  is  re- 
corded only  twice  among  women  (one  per  cent),  as  against 
141  times  among  men  (six  per  cent).  Yet  one  occasionally 
sees  it  in  the  mouth  of  a  syphilitic  who  has  never  smoked. 

Characteristics  of  the  Lesion. — The  typical  lesion  of 
leukoplakia  consists  in  a  whitish,  grayish,  or  opalescent  dis- 
coloration of  the  mucous  membrane.  It  has  a  thickish  look 
but  no  palpable  density,  and  is  not  perceptibly  raised  above 
the  surrounding  surface. 

The  lesions  are  usually  multiple  and  vary  widely  in  size 
and  shape.  The  smaller  ones  are  usually  oval,  and  the  larger 
confluent  lesions  may  have  circinate  edges;  but,  in  many 
instances,  although  this  circinate  character  may  be  discerned 
at  some  part  of  the  patch,  the  general  outline  is  quite 
irregular. 

Intermingled  with  these  typical  lesions  one  commonly  sees 
reddish  areas  where  the  mucous  membrane  of  the  tongue  has 
lost  its  papillary  character  (the  glossite  depapillante  of  Four- 
nier),  and  presents  a  glistening,  polished  aspect.  In  other 
places  the  surface  may  be  eroded  or  ulcerated  and  the  tissues 


354      TERTIARY   SYPHILIS    OP   MOUTH,    PHARYNX,    ETC. 

of  the  tongue  thickened  by  sclerotic  glossitis,  or  (rarely)  de- 
stroyed by  gumma. 

These  lesions  occupy  the  terminal  third  of  the  tongue  and 
are  usually  grouped  about  its  edge,  whence  they  extend  com- 
monly over  the  dorsum,  rarely  very  far  on  to  the  under  surface. 

All  of  these  lesions  are  based  on  the  one  pathological 
process.  The  depapillated  patches  represent  areas  of  squa- 
mous syphilid.  The  leukoplakia  is  the  same  process  with  a 
greater  thickening  of  the  epithelium;  while  sclerotic  glossitis 
simply  represents  a  deep  extension  of  the  same  process,  and 
erosion,  ulcer,  and  gumma  are  expressions  at  different  depths 
of  the  degenerative  tendency  of  the  sclerotic  tissue. 

Diagnosis. — The  appearance  of  such  a  polymorphic  lesion 
as  that  just  described  is  pathognomonic  of  syphilis.  But  when, 
as  sometimes  occurs,  the  whitened  patches  of  leukoplakia  ap- 
pear unaccompanied  by  any  of  these  kindred  changes,  and 
unassociated  with  syphilitic  lesions  elsewhere  in  the  body,  one 
may  doubt  their  nature.  It  is  safe,  however,  to  assume  that 
every  leukoplakia  is  syphilitic  until  it  is  proven  not  to  be. 
Presumptive  evidence  of  syphilis  is  afforded  by  the  history, 
the  presence  of  other  syphilitic  lesions,  the  coexistence  of  ulcer 
or  gumma  upon  the  tongue,  while  the  absence  of  syphilis  is 
presumptive  if  the  lesion  is  papillomatous.  The  test  of  treat- 
ment alone  decides  the  case ;  but  in  chronic  severe  cases  it  may 
be  impossible  to  cure  a  truly  syphilitic  lesion. 

Prognosis.  —  Leukoplakia  is  one  of  the  most  inveterate 
lesions  of  syphilis.  Cases  lasting  four  or  five  years  are  not 
uncommon,  and  one  occasionally  sees  them  continue  for  ten 
or  twenty.  The  most  important  element  in  prognosis  is  the 
use  of  tobacco.  If  the  patient  will  give  this  up  while  the  dis- 
ease is  yet  young  he  may  expect  an  entire  cure;  but  if  he  keeps 
up  the  irritation  of  smoking  or  chewiHg  tobacco,  no  amount 
of  treatment  is  likely  to  cure  the  lesions.  On  the  other  hand, 
after  the  case  has  been  neglected  for  five  or  ten  years,  the 


LEUKOPLAKIA  355 

lesions  become  so  chronic  that  they  are  often  incurable  under 
any  circumstances. 

The  most  important  question  in  the  prognosis  of  leuko- 
plakia is  the  occurrence  of  epithelioma.  Most  authors  speak 
of  it  as  common.  But  among  my  cases  I  have  known  only 
two  to  undergo  epitheliomatous  change.  Yet  I  have  seen  24 
cases  in  which  the  lesions  had  lasted  more  than  three  years, 
while  in  8  of  these  the  lesions  had  lasted  from  ten  to  fifteen 
years. 

The  two  cases  of  epithelioma  occurred  one  twenty-seven 
years,  the  other  thirty  years  after  the  chancre.  In  the  latter 
case  the  leukoplakia  was  known  to  have  existed  for  twenty 
years. 

Treatment. — There  are  three  essentials  to  treatment: 

1.  Removal  of  irritation,  notably  the  irritation  of  tobacco; 
less  frecjuently  that  of  a  jagged  tooth  or  of  spicy  viands. 

2.  Repeated  cauterization  with  liquor  hydrargyri  nitratis, 
as  for  the  secondary  lesions.  The  more  superficial  the  leuko- 
plakia, the  more  effective  this  cauterization.  If,  after  repeated 
efforts,  cauterization  fails,  it  is  vain  to  continue  it  indefinitely. 
The  actual  cautery  has  been  employed  (Barthelemy,  Perrin)  to 
burn  out  the  lesions  with  alleged  excellent  results,  but  I  have 
never  used  it. 

3.  Specific  treatment.  Unless  there  is  ulcer  or  gumma 
accompanying  the  leukoplakia,  httle  good  may  be  expected 
from  the  use  of  iodid.  Small  doses  of  iodid  may  be  employed 
with  the  mercury,  but  this  latter  drug  is  our  chief  reliance. 
In  early  and  superficial  cases  mercury,  administered  by  mouth 
or  by  inunction,  together  with  the  stopping  of  tobacco,  and 
cauterization  with  the  liquor  hydrargyri  nitratis  will  often 
cure.  But  if  these  fail,  or  if  the  condition  persists  in  relaps- 
ing, recourse  should  be  promptly  had  to  injections  of  insoluble 
salts  of  mercury,   lest  too  great   delay  permit   the  lesion  to 

become  so  ingrained  that  no  cure  is  possible. 
25 


356      TERTIARY    SYPHILIS    OF    MOUTH     PHARYNX,    ETC. 

DIFFUSE    SCLEROTIC    GLOSSITIS 

The  lesion  is  a  diffuse  sclerosis  in  the  muscle  of  the 
tongue.  It  is  quite  rare  and  is  always  accompanied  by 
superficial  glossitis,  either  simple  depapillation  or  leuko- 
plakia. 

It  appears  as  a  thickened  and  dark  red  induration  within 
the  substance  of  the  tongue,  and  surmounted  by  an  area  of 
leukoplakia  or  of  glossy  infiltration.  There  are  usually  sev- 
eral such  indurations,  and  the  process  may  involve  the  whole 
tongue. 

In  such  cases  the  tongue  is  much  thickened ;  its  dorsum 
is  lobulated  and  shining,  with  only  here  and  there  an  irregular 
area  in  which  the  normal  papillae  remain.  These  papilla  are 
rather  abnormally  white.  The  tongue  itself  has  a  hard,  car- 
tilaginous density ;  it  is  insensitive  and  clumsy.  The  sclerosis 
is  not  painful,  but  secondary  fissures  and  excoriations  occur 
which  are  quite  sensitive.  With  cessation  of  the  active  syphi- 
litic process  there  is  a  gradual  and  progressive  shrinking  of 
the  scar  tissue,  which  leaves  the  tongue  much  smaller  than 
normal. 

The  prognosis  of  interstitial  glossitis,  like  that  of  all 
syphilitic  interstitial  inflammations,  is  extremely  bad.  If 
attacked  early  and  vigorously  by  hypodermic  injections  of 
mercur3^  it  may  be  cured  in  many  instances,  and  at  least 
checked  in  most;  but  if  neglected,  and  especially  if  irritated 
by  continued  smoking  or  chewing  of  tobacco,  it  becomes  abso- 
lutely intractable  to  treatment ;  for,  though  the  syphilitic  proc- 
ess may  still  be  stayed,  the  scar  remains  indelible. 

GUMMA    OF    THE    TONGUE 

Gumma  of  the  tongue  is  relatively  rare.  One  third  of  the 
cases  are  associated  with  sclerosis  of  the  tonsfue. 


GUMMA   OF   THE   TONGUE 


357 


Gumma  may  be  single  or  multiple,  superficial  or  deep.  Its 
general  characteristics  are  comparable  to  those  of  the  same 
lesion  in  the  skin. 

In  its  hard  stage  it  appears  as  a  deep,  submucous  lump, 
which  softens,  resembles  an  abscess,  and  then  breaks,  leaving 
a  characteristic  deep  syphilitic  ulcer. 

Gumma  commonly  opens  in  the  dorsum  of  the  tongue, 
rarely  upon  its  edge,  never  upon  its  under  surface.  It  may 
afifect  any  part  of  the  tongue  from  the  epiglottis  to  the  tip. 
It  is  usually  a  rapidly  growing  lesion. 

It  is  curable  by  mixed  treatment,  with  insistence  on  iodids. 

It  is  to  be  distinguished  from  epithelioma  by  the  chiric- 
teristics  indicated  in  the  following  table: 


EPITHELIOMA 

1.  Occurrence.  —  Almost   ex- 

clusively   in    men    over 
forty-five  years  of  age. 

2.  Situation.  —  Usually     on 

edge;  may  be  on  under 
surface. 

3.  Number. — Single. 

4.  Leukoplakia.  —  May   pre- 

cede. 

5.  Characteristics.  —  A    shal- 

low, f  ungating  ulcer, 
with  thick,  everted  edges, 
upon  a  base  of  wooden 
hardness.  It  bleeds  very 
readily;  its  discharge  is 
foul. 

6.  'Pain. — Severe    and    lanci- 

nating-. 


GUMMA 

1.  Any  age;  either  sex.     His- 

tory of  previous  syphilis. 

2.  Usually  on  dorsum.    Never 

on  under  surface. 

3.  May  be  multiple, 

4.  May  accompany. 

5.  A    deep,    sloughing   ulcer, 

with  sharp,  undermined 
edges,  upon  a  moderate- 
ly indurated  base.  It 
does  not  bleed  readily; 
its  discharge  is  not  very 
foul. 

6.  Slight  or  absent. 


358      TERTIARY    SYPHILIS    OF   MOUTH,    PHARYNX,    ETC. 
EPITHELIOMA  GUMMA 

7.  Lymph  Nodes. — Soon  and     7.  Enlargement  slight  or  ab- 

progressively  enlarged.  sent. 

8.  Biopsy. — Epithelial  pearls.      8.  Gumma. 

9.  Treatment. — No  medicines     9.  Mixed  treatment  cures. 

have  the  least  effect. 

The   differentiation    from    tuberculosis    has    already    been 
given  (page  251). 


TERTIARY    LESIONS    OF    THE    TONSIL 

The  tonsil,  like  the  tongue,  is  subject  to  gumma  and  to 
interstitial  infiltration.  But  infiltration  of  the  tonsil"  is  only 
slightly  more  common  than  gumma.  It  is  not  accompanied 
by  any  leukoplakia  upon  the  surface  and  is  usually  quite  readily 
curable.  It  does  not,  therefore,  assume  the  importance  of  the 
sclerotic  lesions  of  the  tongue,  and  is  generally  overlooked. 

Infiltration  of  the  Tonsil. — The  lesion  comes  on  quite 
rapidly  and  either  causes  no  sensation  at  all  or  else  excites  a 
slight  soreness  in  the  tonsil. 

Inspection  reveals  a  characteristic  picture.  The  tonsil 
looks  as  though  it  had  been  compressed  from  before  back- 
ward. Instead  of  projecting  as  a  round  mass  it  has  a  sharp, 
notched  edge.  We  may  characterize  it  as  "  hatchet-edged." 
In  color  it  is  dark,  its  surface  is  dense  and  somewhat  glossy. 
The  normal  pittings  are  few  and  shallow. 

Treatment. — This  lesion  yields  kindly  to  mixed  treat- 
ment.    Cauterization  is  harmful. 

Gumma. —  I  have  never  seen  tonsillar  gumma  before  ul- 
ceration. When  ulcerated  it  appears  as  a  deep,  sloughing, 
sharp-edged  mass  surrounded  by  a  dark  indurated  areola. 
Contrary  to  the  usual  rule,  the  glands  behind  the  angle  of  the 


TERTIARY   LESIONS    OF   THE    VELUM  359 

jaw  may  be  inflamed  and  sensitive  (mixed  infection).  The 
tissues  about  the  tonsil  are  usually  somewhat  swollen ;  excep- 
tionally there  is  a  complicating'  acute  tonsillitis,  with  fever  and 
great  pain.  In  such  cases  it  is  impossible  to  make  the  diag- 
nosis until  the  acute  attack  has  passed  by. 

Phagedena  is  rare,  but  I  have  recently  seen  a  case  in  which 
gangrene  of  the  velum  originated  in  a  tertiary  lesion  of  the 
tonsil. 

Treatment. — Mixed  treatment.     No  cauterization. 


TERTIARY  LESIONS    OF    THE    PHARYNX 

The  tertiary  lesions  of  the  pharynx  may  originate  in  the 
mucous  membrane,  in  the  submucous  tissue,  or  in  the  bones. 
The  lesion  always  begins  as  an  infiltration,  and  this  quickly 
breaks  down. 

Thus  the  three  types  are :  Ulcerative  tubercular  syphilid, 
submucous  gumma,  and  gumma  of  the  bone. 

The  lesions  may  be  circumscribed  or  diffuse,  single  or 
multiple.  Though  phagedena  is  infrequent,  the  pharynx  is 
sometimes  involved  with  the  velum  in  a  phagedenic  process 
(see  below).  The  lesions  are  sometimes  cjuite  painful,  and 
may,  by  shutting  ofif  the  Eustachian  tube,  give  rise  to  suppu- 
rative complications  in  the  middle  ear. 

Treatment. — Cauterization  is  harmful ;  mixed  treatment 
effects  a  cure.  The  treatment  of  adhesions  following  phage- 
dena is  mentioned  on  next  page. 

TERTIARY    LESIONS    OF    THE    VELUM 

The  velum,  or  soft  palate,  may  be  the  site  of  interstitial 
sclerosis  or  of  superficial  (tubercular  syphilid)  circumscribed 
ulcers,  but  these  lesions  are  extremely  rare  and  relatively 
unimportant. 


360      TERTIARY    SYPHILIS    OF    MOUTH,    PHARYNX,    ETC. 

The  typical  and  terrible  lesion  of  syphilis  in  the  velum  is 
the  phagedenic  gummatous  ulcer  (Fig.  49). 

This  begins  as  a  diffuse  infiltration,  producing  redness, 
tumefaction,  and  relative  immobility  of  the  velum.  But  it 
causes  scarcely  any  pain,  and  the  patient  usually  pays  no  atten- 
tion to  it  until,  suddenly,  ulceration  and  phagedena  set  in. 

The  onset  of  phagedena  is  exceedingly  rapid.  The  patient 
goes  to  bed  at  night  thinking  himself  well,  and  awakes  with 


Fig.  49. — Ulcers  of  the  Soft  Pal- 
ate.     (Shurley,  after  Du  Blois.) 


Fig.  50. — The  Same:  Healed. 
(Shurley,  after  Du  Blois.) 


a  hole  in  his  palate,  or  with  great  patches  of  necrosis  replac- 
ing what  the  day  before  was  a  comparatively  innocent,  pain- 
less infiltration.  Even  now  the  pain  is  not  great,  and  the 
discomfort  is  inconsiderable.  But  the  foul  odor  from  the 
sloughing  tissue,  or  the  sense  of  a  hole  in  the  velum,  soon 
brings  the  patient  to  his  physician. 


TERTIARY    LESIONS    OF    THE    VELUM  361 

Examination  then  reveals  either  an  area  of  dark  greenish 
slough  in  the  palate,  or  else  a  perforation  surrounded  by  a 
slough.  If  the  perforation  is  of  any  size  the  voice  assumes 
a  nasal  quality  and  the  breathing  may  be  accompanied  by  a 
rattling  gurgle,  due  to  the  flapping  to  and  fro  of  partially 
detached  bits  of  the  palate.  When  the  patient  tries  to  swallow 
he  has  great  difficulty  in  preventing  fluids  from  regurgitating 
through  the  perforation  into  his  nose.  Before  long,  if  the 
lesion  is  a  severe  one,  the  surrounding  tissues,  the  palate, 
the  pharynx,  the  pillars  of  the  fauces,  the  tonsils,  even  the 
base  of  the  tongue  are  invaded,  and,  on  account  of  a  mixed 
infection  of  this  large,  sloughing  area,  the  patient  is  racked 
with  fever  and  his  neck  is  swollen  by  inflamed,  sensitive 
nodes. 

Prognosis. — The  prognosis  of  many  of  the  lesions  of 
syphilis  is  absolutely  under  the  control  of  the  physician.  But 
that  of  gangrene  of  the  velum  is  often  a  matter  of  fortune. 
Some  cases,  even  though  untreated,  produce  only  a  slight 
gangrene  with  infinitesimal  perforation;  indeed  (most  excep- 
tionally) there  may  be  no  perforation  at  all.  But  in  the  ordi- 
nary case  a  considerable  part  of  the  palate  is  destroyed,  leav- 
ing a  deformity  which  consists  either  of  a  perforation  or  of 
an  extensive  erosion  of  the  free  border  of  the  palate  with 
destruction  of  the  uvula.  If  the  perforation  of  the  palate  is 
small,  not  more  than  one  quarter  of  an  inch  in  diameter,  its 
ultimate  healing  may  be  expected  (Fig.  50),  and  in  order  to 
encourage  this  healing  after  the  active  process  has  been  con- 
trolled, the  perforation  may  be  lightly  touched  every  third 
day  with  the  solid  stick  of  nitrate  of  silver.  In  the  meanwhile 
the  patient  may  wear  an  obturator  in  order  to  prevent  irrita- 
tion of  the  hole  by  reflux  of  fluids  through  it. 

Those  unfortunate  victims  whose  lesions  extend  to  the 
pharynx  are  left  in  a  truly  pitiable  condition.  For  not  only 
does  the  deformed  velum  permit  reflux  of  fluids  into  the  nose, 


362       TERTIARY    SYPHILIS    OF    MOUTH,    PHARYNX,    ETC. 

but  also  the  healing  of  the  extensive  ulceration  is  followed  by 
adhesion  of  the  remains  of  the  velum  to  the  lateral  or  posterior 
pharyngeal  wall.  As  these  scarred  tissues  heal  they  contract 
until  the  posterior  nares,  or  even  the  pharynx  itself,  is  almost 
completely  obliterated,  gravely  interfering  with  deglutition, 
speech,  and  even  breathing. 

Treatment. — As  stated  above,  the  extent  of  the  lesion 
depends  more  upon  good  fortune  than  upon  medical  skill.  So 
rapidly  does  the  gangrene  spread  that  it  is  impossible  to  check 
it  immediately  by  any  drugs. 

The  patient  should  be  put  in  the  best  hygienic  surround- 
ings possible  and  overdosed  with  milk  if  he  can  swallow  it. 
In  the  meanwhile  mercury  is  given  by  inunction  or  by  hypo- 
dermic, and  iodids  pushed  as  rapidly  as  may  be.  In  a  severe 
case  it  is  proper  to  push  the  iodids  to  the  point  of  rendering 
the  patient  moderately  delirious;  but,  once  this  point  of  in- 
toxication is  reached,  all  internal  medication  must  be  stopped, 
whether  the  lesion  is  conquered  or  not ;  for  to  keep  the  patient 
poisoned  with  iodid  will  never  cure  the  lesions  of  syphilis. 
When  the  active  process  is  checked,  either  by  the  lapse  of  time 
or  the  effect  of  medicine,  the  patient  must  be  closely  watched 
to  prevent  adhesion  of  the  palate  to  the  pharynx.  This  may 
be  in  large  measure  prevented  by  occasionally  hooking  out  the 
palate;  but  if  such  efforts  fail,  it  may  have  to  be  freed  by  a 
plastic  operation,  the  detail  of  which  differs  with  every  case. 
An  obturator  ^  may  be  applied  after  the  active  process  sub- 
sides, and  kept  in  place  until  all  perforations  are  healed.  For 
a  persistent  perforation  the  obturator  may  be  worn  perma- 
nently, or  an  attempt  may  be  made  to  close  the  hole  by  a 
plastic  operation. 

1  Cf.  Schadle,  St.  Paul  Med.  J.,  1905,  March. 


TERTIARY    LESIONS    OF    THE    NOSE  363 

TERTIARY    LESIONS    OF    THE    PALATE 

Superficial  infiltratiojis  and  ulcerations  of  the  hard  palate, 
like  those  of  the  velum,  are  hoth  rare  and  unimportant,  while 
perforating  giumna  of  the  palate  is  as  insidious,  as  rapid  in 
evolution,  and  almost  as  destructive  in  its  results  as  the  same 
lesion  in  the  velum. 

Gumma  of  the  hard  palate  usually  begins  upon  its  nasal 
surface  as  a  submucous  infiltration.  Since  it  causes  neither 
pain  nor  obstruction,  the  patient  does  not  notice  it  until  he  is 
surprised  to  find  a  hole  through  the  roof  of  his  mouth. 

The  earliest  one  sees  these  lesions  is  when  the  necrotic 
bone  has  not  been  separated,  but  appears  as  a  black,  sloughing 
spot,  or  a  black  or  white  sequestrum  of  dead  bone  surrounded 
by  an  angry  inflamed  circle  in  the  midst  of  the  palate.  Happily 
this  perforation  is  usually  very  small.  Exceptionally  (seven 
times  in  28  cases)  it  is  associated  with  necrosis  of  the  nasal 
septum;  ^  still  more  rarely  (twice)  with  gangrene  of  the  velum. 

Treatment. — Sequestra  must  be  removed  as  soon  as  they 
separate.  High  doses  of  iodid  must  be  depended  upon  to  con- 
trol the  progress  of  the  lesion.  Its  healing  (after  the  active 
process  has  been  checked)  may  be  encouraged  by  an  obturator 
and  applications  of  nitrate  of  silver,  and  if  the  perforation 
cannot  be  closed  by  this  means,  the  patient  must  choose  be- 
tween obturator  and  operation. 

TERTIARY    LESIONS    OF    THE    NOSE 

Gumma. —  Gumma  of  the  nasal  tones  is  always  "  insidious 
and  rapidly  destructive  in  its  onset,  like  that  of  the  palate  and 
the  velum. 


1  The  frequency  of  such  complication  depends  chiefly  upon  the  length  of 
time  the  lesion  is  neglected. 

2  Though  superficial  secondary  mucous  papules  and  ulcers  are  not  uncom- 
mon they  are  habitually  overlooked  and  heal  spontaneously. 


364      TERTIARY    SYPHILIS    OF    MOUTH,    PHARYNX,    ETC. 

The  tissues  most  frequently  involved  are  the  bony  septum 
(51  cases),  the  palate,  i.  e.,  the  floor  of  the  nose  (28  cases), 
the  cartilage  (7  cases),  the  turbinates  (3  cases).  Septum  or 
palate  may  be  implicated  alone.  Cartilage  or  turbinate  is 
never  involved  except  with  the  bony  septum. 

Symptoms. — Exceptionally  the  gumma  is  seen  as  a  little 
dark-red  tumor  before  perforation;  usually  it  is  not  seen  until 
more  or  less  extensive  destruction  of  the  bones  has  occurred. 
The  symptoms  that  bring  the  patient  to  the  physician  are 
obstruction  of  one  nostril  (rarely  both),  slight  pain  (though 
this  may  be  increased  by  secondary  septic  involvement  of  the 
accessory  sinuses),  and  the  casting  off  of  a  great  quantity  of 
foul,  bloody  scabs,  amidst  which  the  patient  rarely  recognizes 
fragments  of  bone. 

Close  questioning  reveals  the  fact  that  the  first  symptom 
noticed  by  the  patient  is  an  increase  in  the  discharges  from 
his  nose  and  the  presence  of  blood  in  these  discharges.  He 
will  also  confess  that  the  sense  of  smell  is  either  blunted  or 
completely  lost. 

Examination  (anterior  rhinoscopy)  reveals  a  perforation 
in  the  septum,  which  is  usually  situated  at  least  an  inch  from 
the  anterior  nares,  though  it  may  appear  at  the  junction  of 
bone  and  cartilage.  This  perforation  is  either  surrounded  by 
a  sloughing  sore  or  else  plugged  with  scabs  and  dead  bone. 
There  are  usually  superficial  ulcerations  in  the  adjacent  tissue, 
and  there  may  be  a  sloughing,  necrotic  mass  on  the  turbinate 
or  a  perforation  in  the  floor  of  the  nose. 

Severe  or  neglected  cases  go  on  to  total  destruction  of  the 
nasal  septum,  and  may  be  identified  the  moment  they  enter 
one's  office  by  the  peculiar  snuffiing,  purring  sound  due  to  the 
flapping  of  necrotic  tissue  excited  by  the  breathing.  The  re- 
sult of  such  extensive  destruction  is  at  first  a  considerable 
edema  and  soreness  of  the  nose  externally.  When  in  this 
condition  the  nose,  if  gently  moved  from  side  to  side,  emits 


TERTIARY   LESIONS   OF   THE    NOSE 


365 


a  crackling  sound  indicative  of  the  multiple,  irregular  per- 
forations in  all  its  bony  structures. 

With  the  healing  of  such  a  lesion  the  bridge  of  the  nose 
sinks  in,  and  may  even  fall  flat  to  the  level  of  the  patient's 
face  if  all  of  the  bones  have  been  destroyed.  The  deformity, 
if  chiefly  due  to  bone  destruction,  is  saddle-backed  (Fig.  51), 


Fig.    51. — Loss    of    Septum:    Acquired    Syphilis. 
(Cf.  Figs.  63,  64,  p.  511.)     (Fordyce.) 

while  the  more  rare  destruction  of  the  cartilage  produces  a 
deformity  en  lorgnette  (like  an  opera  glass),  which  looks  as 
though  the  lower  third  of  the  nose  had  been  partially  pushed 
up  inside  the  upper  two  thirds. 


366      TERTIARY   SYPHILIS    OF    MOUTH,    PHARYNX,    ETC. 

Still  more  virulent  cases  resulting  in  extensive  perforation 
of  the  accessory  sinuses,  cicatricial  obstruction  of  the  lac- 
rymal  ducts  or  of  the  Eustachian  tubes,  complete  destruction  of 
the  soft  parts  of  the  nose,  and  invasion  through  the  ethmoidal 
cells  of  the  meninges,  with  consequent  fatal  septic  meningitis, 
are  so  uncommon  as  to  deserve  only  a  passing  mention. 

Diagnosis. — The  importance  of  an  early  diagnosis  cannot 
be  overestimated,  and  the  only  way  to  achieve  this  is  to  put 
the  patient  on  his  guard.  Bid  him,  if  he  blozvs  bloody  scabs 
from  his  nose,  report  at  once. 

Treatment. — Mixed  treatment,  with  high  doses  of  iodid, 
is  required  in  the  virulent  cases,  though,  in  most  instances,  a 
mild  course  is  quite  sufficient.  The  nose  must  be  kept  clean 
by  douching  or  spraying  with  oil  or  by  the  application  of 
boric-acid  ointment.  Sequestra  must  be  removed  as  rapidly 
as  possible,  but  no  other  local  treatment  should  be  attempted. 

Other  Rare  or  Obscure  Conditions. — The  destructive 
lesions  above  described  tell  almost  the  whole  story  of  ter- 
tiary nasal  syphilis.  But  other  rarer  conditions  also  merit 
mention.-^ 

Syphiloma. — This  name  has  been  given  by  the  Germans 
to  a  very  rare  tumor,  usually  a  complication  of  syphilitic 
septal  perforation  and  growing  from  the  septum  (though 
it  may  grow  from  the  inferior  turbinate  or  in  the  naso- 
pharynx). It  is  grayish  or  reddish  in  color,  usually  soft  in 
consistency,  and  may  attain  a  considerable  size.  It  is  usually 
confused  with  tuberculoma.  It  disappears  promptly  under 
mixed  treatment. 

Fibroid  Degeneration  of  the  Turbinates. — Described 
by  Mackenzie. 

Atrophic  Rhinitis. — The  healing  of  a  septal  gumma 
almost  always  leaves  more  or  less  atrophy  of  the  mucous  mem- 

>  Cf.  Renner,  N.  Y.  Med.  J.,  1904,  February  8,  15,  22. 


TERTIARY    SYPHILIS    OF    THE    EAR  367 

brane,  which  is  interpreted  by  Lang,  Gerber,  and  other  Ger- 
man authors  as  truly  syphihtic  (not  a  mere  comphcation). 

Moreover,  there  seems  reason  to  beHeve  that  cases  of 
atrophic  rhinitis  beginning  at  about  the  age  of  puberty  may 
bear  some  relation  to  antecedent  hereditary  syphilis.^ 

TERTIARY   SYPHILIS   OF   THE   EAR 

Apart  from  the  tertiary  skin  lesions  which  may  affect  the 
outer  ear,  and  otitis  media  which  may  result  from  syphilis 
of  the  adjacent  bones,  the  only  type  of  tertiary  syphilis  of  the 
ear  is  the  sudden^  absolute  deafness  due  to  disease  of  the 
inner  ear. 

Syphilis  of  the  Internal  Ear. — The  lesions  of  syphilis  in 
the  inner  ear  are  not  well  known.  ^  Indeed,  the  one  symptom 
is  deafness,  without  any  local  evidences  of  the  disease. 

Since  this  deafness  is,  in  my  experience,  often  associated 
with  other  lesions  of  the  nervous  system,  I  think  it  preferable 
to  defer  its  consideration  to  another  chapter  (page  395). 

^  Cf.  discussion  of  Richards's  paper,  /.  Am.  Med.  Ass'n.,  1907,  vol.  xlviii, 
p.  42. 

^  Hennet  (Fournier's  Traiie  de  la  syphilis,  1904,  vol.  ii,  p.  620)  relates 
one  autopsy  showing  a  secondary  periostitis. 


CHAPTER    XXV 
SYPHILIS  OF   THE  NERVOUS  SYSTEM^ 

Grouping  the  lesions  of  syphilis  according  to  the  tissues 
involved,  one  may  affirm  that  syphilis  of  the  skin  is  the  most 
frequent,  syphilis  of  mucous  membranes  the  most  infectious, 
syphilis  of  the  nervous  system  the  most  malignant  manifesta- 
tion of  the  disease.  Syphilis  of  the  nervous  system  is  indeed 
malignant  in  that  it  occurs  in  a  large  proportion  of  syphilitics 
and  that  its  lesions  are  always  grave  and  often  incurable. 

Thus,  among  my  2,500  cases,  504  (twenty  per  cent)  were 
afflicted  with  syphilis  of  the  nervous  system,  and  of  all  patients 
showing  tertiary  and  parasyphilitic  lesions,  forty-two  per  cent 
were  affected  in  the  nervous  system.  Moreover,  39  died 
paretic;  113  were  more  or  less  disabled  by  tabes;  10  (at  least) 
died  insane,  and  7  others  of  various  paralyses;  while,  of  the 
remainder,  about  one  fifth  were,  permanently  and  gravely  dis- 
abled. To  admit  (in  round  numbers)  60  deaths  and  175 
cases  of  permanent,  though  often  moderate,  disability,  is  hard, 
but  necessary.  Such  are  the  results  of  syphilis  of  the  nervous 
system  as  we  find  it  recorded. 

ETIOLOGY 

One  must  distinguish  the  effects  of  race,  sex,  age,  treat- 
ment, and  alcohol. 

Race. — X'ot  only  are  full-blooded  members  of  the  yellow, 
brown,  and  black  races  almost  entirely  immune  to  the  para- 

'  Reviewed  by  Dr.  E.  G.  Zabriskie. 
368 


ETIOLOGY  369 

syphilids,  but  they  also  possess  a  relative  immunity  to  all 
syphilids  of  the  nervous  system.  Despite  utter  neglect  of 
medicine  or  hygiene  they  escape  in  far  larger  proportion 
than  we  do. 

Sex. — Only  21  cases  (ten  per  cent)  are  recorded  among 
women,  against  483  (twenty-one  per  cent)  among  men. 

Age. — The  effect  of  age  is  marked.  Comparing  lesions 
of  the  nervous  system  with  all  other  tertiaries : 

Of  men  infected  under  twenty  years  of  age,  18  =  31  per 
cent  N.  S.^ 

Of  men  infected  between  the  ages  of  twenty  and  twenty- 
nine,  199  =  43  per  cent  N.  S. 

Of  men  infected  at  or  after  thirty,  147  =^51  per  cent  N.  S. 

Moreover,  the  older  the  victim  at  the  time  of  infection, 
the  earlier  the  outbreak  of  his  syphilis  in  the  nervous  system, 
thus : 

Of  men  infected  before  twenty,  only  one  had  N.  S.  within 
two  years. 

Of  men  infected  between  twenty  and  twenty-nine,  12  had 
N.  S.  within  one  year,  41  within  two  years. 

Of  men  infected  after  thirty,  31  had  N.  S.  within  one  year, 
51  within  two  years.^ 

Thus  the  older  the  man  at  the  time  of  infection,  the  more 
likely  is  he  to  have  N.  S.,  and  the  sooner  will  it  begin. 

Treatment. — As  far  as  the  prolonged  taking  of  mercury  is 
concerned,  I  find  that  120  were  well  treated,  in  that  they  took 
mercury  at  least  eighteen  months;  while  124  were  ill  treated, 
in  that  they  took  it  not  at  all  or  for  a  shorter  time  than  eighteen 
months.  But,  dividing  the  patients  into  three  classes  by  age, 
as  in  the  preceding  computations,  I  find  that : 

^  Syphilis  of  the  nervous  system. 

^  Or,  to  express  it  still  more  forcefully — in  the  youngest  class,  half  of  N.  S. 
began  in  the  eleven  years  following  chancre;  in  the  medium  class,  half  began 
within  five  years;  in  the  older  class,  within  three  years. 


370  SYPHILIS    OF   THE    NERVOUS    SYSTEM 

Of  the  youngest  class,  4  were  "  well  "  treated,  9  "  ill  " 
treated. 

Of  the  medium  class,  45  were  "  well  "  treated,  72  "  ill  " 
treated. 

Of  the  older  class,  51  were  "well"  treated,  43  "ill" 
treated. 

This  is  what  one  might  expect :  the  older  man  takes  better 
care  of  himself  than  the  younger;  nevertheless,  the  older  man 
is  more  afflicted  with  N.  S.  than  the  younger. 

This  proves,  if  it  proves  anything,  that  mercurial  treat- 
ment, as  currently  employed,  has  a  relatively  slight  inhibitory 
effect  upon  N.   S.^ 

Alcohol. — My  records  relate  only  to  marked  and  per- 
sistent alcoholism.  Of  this  class,  151  had  tertiary  lesions  and 
only  61  N.  S.  Improbable  as  it  may  seem,  three  fifths  of 
the  alcoholics  who  showed  tertiary  syphilis  escaped  as  to  their 
nervous  system.  Thus,  however  much  alcohol  may  predis- 
pose a  patient  to  N.  S.,  it  alone  cannot  be  invoked  as  a  con- 
stant and  essential  cause. 

Summary. — If  it  be  not  alcohol,  what  is  it  that  makes  men 
rather  than  women  suffer  from  syphilis  of  the  nervous  system, 
white  men  rather  than  those  of  another  hue,  older  men  rather 
than  younger  men,  and  that  in  defiance  of  mercurial  treatment  ? 

The  question  is  not  an  easy  one  to  answer.  Alcohol  is 
in  large  measure  answerable  for  tertiarism  in  general,  and  in 
some  degree  for  syphilis  of  the  nervous  system  as  well;  just 
as  mercurial  treatment  is  surely  in  some  measure  preventive. 
But  the  chief  etiological  factor  is  doubtless  the  "  civilization  " 
which  Kraft-Ebing  has  linked  with  syphilis  as  the  cause  of 
paresis. 

1  The  statistics  of  most  Continental  -writers  suggest  a  marked  beneficial 
influence  from  proper  treatment.  The  insurmountable  difficult}'  is  to  learn 
just  what  constitutes  "good  treatment,"  and  whether  it  has  been  employed  in 
a  given  case. 


ETIOLOGY 


371 


One  naturally  supposes  neurotic  or  neuropathic  persons 
more  liable  than  others  to  nervous  syphilis.  Yet  if  this  be  so, 
I  know  some  glaring  exceptions  to  the  rule. 

But  the  men  most  susceptible  to  syphilis  of  the  nervous 
system  appear  to  be  those  who  live  hard  or  high ;  those  who 
slave  or  sport;  those  who  live  the  fierce  life  of  cities  rather 
than  those  who  dwell  in  the  better  hygiene  and  the  calmer 
surroundings  of  the  country.  The  underlying  idiosyncrasy 
which  causes  some  such  men  to  fall  victims,  while  others 
escape,  we  do  not  know. 

Date  of  Onset. — Although  all  authorities  agree  that  syphi- 
lis of  the  nervous  system  is  by  no  means  an  essentially  late 
process,  as  was  supposed  by  the  earlier  writers,  yet  there  is 
considerable  dispute  as  to  the  exact  date  of  maximum  frequency. 
This  dispute  is  founded  upon  a  looseness  in  interpreting  the 
exact  nature  of  the  early  symptoms  which  we  might  call  sec- 
ondary. 

These  symptoms,  consisting  almost  exclusively  of  headache 
and  neuralgias  of  various  kinds,  are  very  common  at  the  onset 
of  syphilis,  and  it  is  highly  probable  that  many  cases  of  syphi- 
lis of  the  nervous  system  have  their  origin  with  the  short- 
lived headache  of  the  early  stages  of  the  disease. 

Yet,  in  speaking  of  syphilis  of  the  nervous  system,  it  is 
impossible  to  take  this  feature  accurately  into  account ;  for  the 
greater  number  of  sufferers  from  early  headache  or  neuralgia 
have  no  subsequent  grave  lesions  of  the  nervous  system. 

Our  cases,  collated  as  accurately  as  possible,  show  a  maxi- 
mum frequency  of  onset  in  the  third  year  of  the  disease,  and 
also  show  that  the  number  of  lesions  of  N.  S.  occurring  in  each 
of  the  first  three  years  far  exceeds  the  number  occurring  in 
any  subsequent  year. 

The  effect  of  age  upon  the  onset  has  already  been  dwelt 
upon.  It  is  to  be  noted,  however,  that  some  of  the  most  impor- 
tant lesions  of  the  disease  are  most  common  in  the  first  and 
26 


372 


SYPHILIS    OF    THE    NERVOUS    SYSTEM 


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PATHOLOGY    OF    BRAIN    LESIONS  373 

second  years.  Such  are  myelitis,  (hemiplegia  ^),  deafness,  and 
facial  paralysis ;  while  ataxia  and  paresis  begin  to  appear  only 
in  the  third  year  and  run  an  average  maximum  about  evenly 
from  the  third  to  the  eleventh  year. 


PATHOLOGY    OF    BRAIN    LESIONS 

The  pathological  changes  produced  by  syphilis  in  the  brain 
were,  until  this  generation,  ill  understood.  Before  the  re- 
searches of  Heubner  (1874)  they  were  reducible  practically  to 
two  classes : 

1.  Cases  of  diffuse  or  localized  infiltration  (sclerosis  and 
gumma),  most  common  in  the  meninges  about  the  base  of  the 
brain,  less  frecjuent  at  other  parts  of  the  meninges,  or  arising 
from  the  bone,  or  apparently  within  the  brain  itself. 

2.  Cases  sine  materia,  in  which  the  pathological  findings 
were  nil. 

Arterial  Lesions. — Heubner  showed  the  nature  of  the 
lesions  in  this  second  class  of  cases  by  discovering  syphilitic 
arteritis  of  the  main  arteries  about  the  base  of  the  brain  and 
their  branches,  even  to  the  arterioles  zvithin  the  brain. 

The  arteritis  begins  with  an  exudation  and  proliferation 
of  the  cells  of  the  intima  (says  Heubner),  which  exudation 
eventually  becomes  organized  into  new  connective  tissue.  This 
thickening  may  involve  considerable,  areas  and  causes  partial 
or  complete  obstruction  of  the  lumen.  By  destroying  the  elas- 
ticity of  the  vessel  wall  it  leads  to  thrombosis,  rupture,  or 
aneurysm. 

Koster  suggested  that  the  process  originated  not  in  the 
intima,  but  in  the  vasa  vasorum;  and  Baumgarten,  in  1878, 
affirmed   that  the   usual   process  was  primarily   in   the   outer 

^  The  onset  of  hemiplegia  is  early  in  the  experience  of  the  syphilologist, 
thougli  the  neurologist,  meeting  it  as  an  isolated  lesion,  does  not  see  many  cases 
before  the  third  year. 


374  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

coats  of  the  artery,  the  invasion  of  the  intima  being  secondary. 
This  periarteritis  is  certainly  the  more  common  lesion,  and  is 
probably  the  underlying  one. 

Berkley  ^  describes  the  gross  changes  observed  as  follows : 

"  Primary  syphilitic  disease  of  the  large  vessels  of  the  brain 
basis  presents  some  peculiar  characteristics  which  serve  to  dis- 
tinguish it,  even  to  the  naked  eye,  from  diffuse  arteriosclerosis 
and  other  degenerations,  though  in  fact  many  of  these  are 
indirectly  caused  by  the  luetic  poison.  At  an  early  stage  the 
blood-vessels  lose  their  semitransparent  character ;  they  become 
opaque  and  acquire  a  peculiar,  whitish  cast,  which  later  as- 
sumes a  gray  tint.  On  cross-section  a  vessel  no  longer  col- 
lapses, but  remains  triangular,  or  at  least  irregular,  in  out- 
line. To  the  touch  the  walls  feel  harder,  and  show  a  tendency 
to  break  on  slight  tension.  On  a  closer  examination  of  the 
lumen  it  is  found  to  be  narrowed  to  perhaps  one  half  of  its 
former  caliber  by  what  is  apparently  a  zone  of  newly  formed 
substance  of  gray  or  whitish  appearance,  which  has  a  dry  and 
cartilaginous  consistency.  Finally,  the  lumen  of  the  vessel 
may  be  entirely  obliterated  by  the  advancing  growth  of  the 
new  formation,  or  thrombi  may  form  in  the  narrowed  channel. 

"  Other  forms  of  syphilitic  degeneration  or  neoplastic  for- 
mation may  now  and  then  be  found.  Miliary  giuTimata  may 
be  strewn  along  the  periphery  of  the  larger  vessels,  or  the  ele- 
ments of  the  adventitia,  nuclear  or  fibrous,  may  proliferate, 
inclosing  the  vessel  in  a  thickened  sheath,  which  gradually 
involves  the  inner  coats,  weakening  the  walls,  and  by  extension 
of  the  proliferating  elements  narrowing  the  lumen." 

Meningeal  Lesions. — Apart  from  acute  early  meningitis, 
of  which  the  lesions  are  not  definitely  known,  syphilitic  men- 
ingitis is  a  tertiary  process ;  either  a  diffuse  infiltration  or  mul- 
tiple localized  gummata.     These  latter  vary  in  size  from  that 

1  "Alental  Diseases,"  Appleton,  1900. 


PATHOLOGY    OF    LESIONS    OF    THE    SPINAL    CORD     375 

of  a  pin's  head  to  a  robin's  egg,  while  the  diffuse  infiltration 
may  cover  a  considerable  area. 

On  the  base  of  the  brain  the  lesions  usually  begin  in  the 
pia  mater  and  extend  very  widely.  The  greatest  infiltration  is 
usually  about  the  optic  chiasm,  and  may  extend  as  far  back  as 
the  meninges  of  the  cord.  The  cranial  nerves  are  affected 
either  by  compression  or  infiltration  (they  may  be  swollen  to 
several  times  their  natural  size),  while  the  brain  itself  becomes 
adherent. 

On  the  convexity  of  the  brain  the  meningitis  is  commonly 
quite  localized;  and  originates  either  in  the  dura  mater  or  in 
the  skull,  thence  extending  inward,  causing  adhesion,  infiltra- 
tion, and  compression  of  the  underlying  brain. 

Arterial  and  meningeal  lesions  often  coincide. 

Gumma  of  the  brain  always  originates  in  the  meninges  or 
in  a  vessel  wall.     It  is  extremely  rare. 

Secondary  Changes. — The  frequent  invasion  of  the  cranial 
nerves  is  a  direct  extension  from  the  common  syphilitic  menin- 
gitis. Hemiplegia  is  due  to  the  arterial  changes,  while  mania 
and  dementia  are  associated  primarily  with  circulatory  im- 
pairment, ultimately  with  actual  secondary  degeneration  or 
infiltration  of  the  brain. 


PATHOLOGY   OF   LESIONS   OF   THE    SPINAL   CORD 

The  pathology  of  the  spinal  lesions  of  syphilis  is  quite  the 
same  as  that  of  the  cerebral  lesions.  The  spinal  meningitis 
is  both  diffuse  and  circumscribed  (gummatous)  ;  arterial  dis- 
ease is  quite  constant  and  leads  to  sclerosis  (or  gumma)  of  the 
cord,  or  permits  hemorrhage  into  it.  But  gumma  of  the  cord 
is  usually  of  meningeal  origin. 

As  in  the  brain,  the  dura  is  rarely  attacked,  and  invasion 
from  a  syphilitic  bone  lesion  is  most  uncommon,  since  efficient 
protection  is  afforded  by  the  intraspinal  fat. 


376  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

The  distribution  of  lesions  is  usually  both  irregular  and 
general ;  moreover,  with  the  spinal  lesions,  cerebral  lesions 
often  coexist. 


LYMPHOCYTOSIS   OF    CEREBRO-SPINAL   FLUID 

"  The  normal  cerebro-spinal  fluid  contains  no  cells,  or  at 
least  only  rarely  a  mononuclear  lymphocyte  or  an  endothelial 
cell  "  (Dana  and  Hastings  ^).  Therefore,  when  Nageotte  and 
other  French  observers  noted  a  marked  lymphocytosis  of  the 
cerebrospinal  fluid  in  cases  of  cerebral  syphilis  as  well  as  in 
the  great  majority  of  recently  infected  syphilitics,  even  in 
those  who  showed  no  evidence  of  cerebral  or  spinal  lesions, 
they  concluded  that  this  lymphocytosis  is  due  to  syphilis 
(though  the  reaction  is  by  no  means  universal).  They  also 
ventured  the  opinion  that  it  is  an  early  sign  of  meningeal  in- 
volvement. But  more  recent  investigations  have  failed  to  con- 
firm this  theory.  Merzbacher  -  has  summed  up  the  evidence 
at  hand,  from  which  it  appears  that : 

1.  The  lymphocytosis  of  syphilis  is  due  to  the  disease  itself 
(toxemia),  not  to  a  meningitis;  for 

2.  This  lymphocytosis  is  very  frequent  in  certain  condi- 
tions that  have  nothing  to  do  wnth  meningitis.  Some  of  these 
are  syphilitic,  e.g.,  tabes,  paresis,  Arg3dl-Robertson  pupil; 
some  non-syphilitic,  e.  g.,  herpes,  multiple  sclerosis,  and 
mumps. 

3.  Precisely  what  causes  this  lymphocytosis  we  do  not 
know.  But  it  certainly  is  not  a  wanting  of  an  impending 
meningeal  outbreak. 

From  another  point  of  view,  however,  this  knowledge  is 
extremely  useful.      For  such   conditions   as  hysteria,   neuras- 

*  Med.  Record,  1904,  January  23. — This  contribution  contains  an  excellent 
description  of  the  technic  of  lumbar  puncture  and  cytodiagnosis. 
^Centralbl.  }ur  Nervenheilk.,  1906,  vol.  xxix,  pp.  304,  352. 


EARLY    SECOxNDARY    MENINGITIS  '    377 

thenia,  and  alcoholism  are  not  accompanied  by  lymphocytosis; 
hence  the  existence  of  cerebrospinal  lymphocytosis  is  pre- 
sumptive evidence  in  favor  of  paresis,  tabes,  or  some  syphilitic 
lesion,  as  against  hysteria,  neurasthenia,  and  alcoholism. 

More  recent  studies  of  the  chemico-physiological  qualities 
of  the  cerebro-spinal  fluid,  though  not  yet  thoroughly  worked 
out,  suggest  that  the  lymphocytosis  is  evidence  of  a  specific 
reaction  excited  by  the  presence  of  spirochetje.  Thus  a  recent 
contribution  ^  concerning  the  complement-deviation  test  re- 
ports positive  results  (presence  of  syphilitic  antibodies)  from 
experiments  with  the  cerebro-spinal  fluid  in  secondary  syphilis 
and  in  paresis. 

The  application  of  these  tests  opens  up  a  new  field  for  in- 
vestigating the  relationship  of  syphilis  to  paresis  and  tabes. 
Thus  far  the  evidence  is  uniformly  favorable  to  linking  the 
two  great  parasyphilids  more  closely  than  ever  with  syphilis. 
We  may  at  least  affirm  that  the  cytological  and  bio-chemical 
changes  usually  found  in  the  cerebro-spinal  ftiiid  of  knozvn 
syphilitics  are  identical  with  those  usually  found  in  tabetics 
and  paretics,  while  differing  from  those  common  to  other 
diseases  of  the  nervous  system. 

EARLY    SECONDARY    MENINGITIS 

The  localized  headache  and  neuralgias  that  so  often  accom- 
pany the  first  outbreak  of  secondary  symptoms  are  perhaps 
due  to  acute  meningitis  or  neuritis. 

The  clinical  type  of  these  pains  has  already  been  described 
(page  264).  Lang  has  noted  that  they  may  be  accompanied 
b)''  mydriasis  and  bradycardia.  Schnabel  (quoted  by  Lang) 
found  retinal  irritation  in  14  and  actual  retinitis  in  7  among 
40  patients  examined  at  this  period  of  the  disease.     The  re- 

*  Virchow's  Archiv,  1907,  vol.  cLxxxviii,  No.  i. 


378  SYPHILIS    OF   THE    NERVOUS    SYSTEM 

markable  feature  of  these  investigations  is  that  the  process 
found,  though  one  would  expect  it  gravely  to  impair  the  sight, 
had  no  such  effect. 

Prognosis. — The  importance  of  these  evidences  of  menin- 
geal irritation  is  the  warning  they  afford.  Every  syphilitic 
headache  or  neuralgia  merits  respect  and  attention  whether  it 
occurs  at  the  onset  or  late  in  the  disease.  Whether  it  disap- 
pears after  a  few  doses  of  iodid  or  proves  intractable,  it  is 
always  an  evidence  of  a  definite  lesion  which  may,  if  neglected, 
lead  to  grave  central  lesions. 

Treatment.  ^ — lodids  cure.  Mercury  prevents  relapse. 
Moderate  doses  of  each  suffice,  but  the  treatment  should  be 
continued  for  weeks  after  the  symptoms  have  subsided. 


SYMPTOMS 

Apart  from  this  early  secondary  meningitis,  the  lesions  of 
syphilis  of  the  nervous  system  have  two  striking  clinical  char- 
acteristics, viz. : 

1.  The  occurrence  of  prodromes. 

2.  The  variety  and  diversity  of  symptoms. 

Prodromes.  —  There  are  five  types  of  preliminary  symp- 
toms, one  or  all  of  which  invariably,  or  almost  invariably, 
precede  the  graver  forms  of  cerebral  or  spinal  syphilis.    These 

are: 

1.  Pain. 

2.  Intellectual  and  moral  derangements. 

3.  Impairment  of  the  general  health. 

4.  Impairment  of  the  sexual  power,  and 

5.  Fugitive  nervous  symptoms. 

Pain. — Syphilis  of  the  spine  may  be  preceded  by  sharp 
pains,  or  girdle  sensations,  or  sensations  of  numbness  or  par- 
esthesia in  whatever  nerves  are  becoming  affected.     But  the 


SYMPTOMS  379 

most  constant  and  premonitory  pain  is  the  headache  which 
precedes  brain  syphiHs.  This  headache,  hke  all  other  syphi- 
litic pains,  has  three  marked  characteristics : 

1.  Nocturnal  exacerbations  with  partial  or  complete  relief 
of  the  pain  by  day. 

2.  Resistance  to  all  the  ordinary  remedies  for  neuralgia, 
and  persistence  of  the  pain  under  their  use,  and 

3.  Prompt  amelioration  or  relief  under  moderate  doses  of 
potassium  iodid.  The  headache  is  often  occipital  and  intense 
and  sharp  in  character,  but  variations  in  situation  and  type 
are  extremely  common. 

Sleeph^ssness  results  from  this  headache. 

Intellectual  and  Moral  Disturbances. — These  are 
common  preliminaries  of  cerebral  syphilis,  but  do  not  precede 
a  purely  spinal  lesion.  They  consist  in  a  diminution  of  all 
foTms  of  cerebral  activity.  The  patient  becomes  gloomy,  even 
melancholy.  He  is  irascible.  His  power  of  concentration  is 
diminished;  his  memory  fails  him;  attention  and  ratiocination 
are  both  impaired. 

Unlike  the  premonitory  pains,  which  are  usually  persistent, 
these  premonitory  intellectual  and  moral  disturbances  are  usu- 
ally somewhat  irregular.  They  may  apparently  improve 
from  day  to  day  for  quite  a  time,  only  to  relapse  again,  or 
they  may  amount  to  actual  dementia  or  mania.  They  are 
quite  frequently  lacking. 

Impairment  of  the  General  Health. — This,  though 
the  least  definite,  is  perhaps  the  most  constant  of  the  premoni- 
tory symptoms  of  syphilis  of  the  nervous  system.  It  consists 
in  a  progressive  loss  of  weight,  often  associated  with  a  sensa- 
tion of  muscular  weakness  and  anorexia. 

Impairment  of  Sexual  Power. — There  is  also  com- 
monly a  slight  but  progressive  diminution  of  sexual  power  and 
desire  in  the  male ;  though  this  is  often  not  called  to  the  atten- 
tion of  the  physician  until,  as  improvement  sets  in,  the  patient 


380  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

recognizes  a  marked  increase  in,  or  rather  a  return  of,  sexual 
vigor.  This  decrease  of  sexual  vigor  is  often  an  important 
early  sign  of  syphilis  of  the  nervous  system,  and  should  always 
be  sought  for. 

Fugitive  Nervous  Symptoms. — Certain  irregular  nerv- 
ous symptoms  precede  almost  every  outbreak  of  syphilis  in  the 
nervous  system ;  but  this  type  of  prodromes  is  essentially  com- 
mon and  characteristic  before  hemiplegia  and  insanity.  Apart 
from  certain  vague,  abnormal  sensations,  which  are  common 
enough  but  difficult  to  characterize,  syphilitic  hemiplegia  is 
invariably  preceded  by  one  or  more  attacks  of  vertigo,  aphasia, 
or  momentary  paralysis. 

The  patient,  while  talking  to  a  friend,  suddenly  finds  him- 
self unable  to  speak  intelligently  {aphasia).  He  is  conscious 
of  what  he  wishes  to  say  and  of  his  inability  to  say  it.  His 
mouth  emits  only  incoherent  words  or  syllables,  and,  ashamed 
at  this  inexplicable  disturbance,  he  endeavors  to  hide  it  by 
silence  or  by  a  pretended  nausea  or  giddiness.  After  a  few 
moments  the  attack  passes,  and  he  readily  persuades  himself 
that  it  was  nothing.  If  he  is  fortunate  enough  to  have  sev- 
eral such  attacks,  he  may  come  to  the  physician  before  the 
onset  of  any  graver  lesion;  but,  as  a  rule,  and  perhaps  on 
account  of  a  concomitant  intellectual  deficiency,  he  pays  no 
attention  to  these  warnings. 

In  other  cases  the  attack  is  a  momentary  vertigo.  While 
walking  along  the  street  he  suddenly  loses  his  balance,  clutches 
a  railing  or  a  friend's  arm  for  a  few  moments,  and  then  it  is 
all  over,  and  he  is  as  well  as  ever. 

Or  he  is  temporarily  paralyzed.  While  sitting  at  the 
table,  he  suddenly  notices  that  he  cannot  hold  his  knife  or 
fork;  or,  while  walking,  his  leg  gives  way  beneath  him; 
but,  as  a  rule,  a  few  moments  suffice  to  set  the  weakness 
aright. 

Convulsive  prodromes  are  less  common. 


SYMPTOMS  381 

Duration  of  the  Preliminary  Period. — These  warn- 
ing symptoms  may  be  few  and  brief,  or  multiple  and  prolonged. 
Severe  syphilitic  headache  or  repeated  attacks  of  vertigo  may 
continue  for  months,  uncontrolled  by  treatment,  and  without 
leading  to  any  further  evidence  of  cerebral  syphilis.  But  in  a 
majority  of  instances  the  warnings  are  so  few  and  so  slight 
that  the  patient  does  not  consult  a  physician  until  the 
full  attack  has  burst  upon  him  (Cases  XXXII,  XXXIII, 
XXXIV). 

Onset. — In  spite  of  prodromata  the  onset  of  symptoms  is 
always  sudden.  The  patient's  story  is  that  "  suddenly — " 
something  happened.  Be  the  attack  a  dementia,  a  paralysis, 
or  a  convulsion  it  develops  suddenly,  and  to  the  untrained 
observer  unexpectedly. 

This  sudden  onset  may  or  may  not  launch  the  patient  into 
the  midst  of  his  attack.  As  a  rule,  the  more  extensive  lesions 
require  at  least  a  few  hours  for  their  full  development,  and 
may  even  progress  for  several  days.  Thus  syphilitic  hemi- 
plegia usually  begins  with  a  sudden,  complete  or  partial,  loss 
of  power  in  a  limb  or  a  group  of  muscles,  which  loss  of  power 
soon  spreads  to  the  whole  side.  But  a$  this  spreading  often 
occupies  but  a  few  hours,  an  unintelligent  patient  usually  re- 
ports the  whole  affair  as  having  occurred  suddenly  (Case  VII, 
page  20). 

Course. — The  course  of  the  manifestation  is,  as  remarked 
above,  characterized  by  a  marked — even  pathognomonic — 
variety  of  symptoms  dependent  upon  the  diversity  and  irregu- 
lar distribution  of  the  lesions  from  which  they  spring. 

The  lesions  of  cerebral  syphilis  are  many  and  complex. 
More  or  less  widespread  gummatous  meningitis  and  more  or 
less  widespread  arterial  changes  may  occur  together.  Hence 
results  an  almost  infinite  diversity  of  clinical  symptoms. 

The  table  on  page  372  shows,  it  is  true,  that  certain  clin- 
ical types  (e.  g.,  hemiplegia  and  the  parasyphilids)  often  stand 


382  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

alone,  \vhile  others  (e.  g.,  ocular  paralysis  and  insanity)  are 
usually  only  one  element  in  a  many-colored  and  confused  pic- 
ture of  nervous  disorder.  But  at  the  beginning  some  one 
lesion  stands  out  most  prominently,  and,  if  this  is  vigorously 
attacked,  there  may  be  no  further  symptoms.  Thus  a  patient 
in  the  prodromal  stage  may  usually  be  cured  by  sharp  treat- 
ment. 

Moreover,  a  single  lesion,  such  as  a  ptosis  or  an  epilepsy, 
may  remain  unique,  even  though  untreated  for  years,  but  this 
is  very  rare.  The  rule  is  an  intermittent  progress  from  one 
lesion  to  another,  unless  the  process  is  checked  by  treatment. 

Relapses  are  therefore  very  common  and  are  the  measure 
of  treatment.  The  better  the  treatment,  the  fewer  and  further 
apart  are  the  relapses. 

Although  it  is  not  possible  absoluteh^  to  separate  all  cases 
according  to  the  underlying  pathological  lesion,  one  may  at- 
tempt a  general  disposition  of  the  cases  under  the  following 
heads : 

Cerebral  Arteritis. — This  leads  usually  to  hemiplegia, 
to  aphasia,  to  nuclear  paralyses  of  the  various  nerves,  and  to 
mental  obfuscation,  drowsiness,  and  loss  of  memory,  or  epi- 
leptiform attacks,  finally  to  insanity. 

Basilar  Meningitis. — There  is  usually  involvement  of 
one  or  more  of  the  cranial  nerves.  There  may  be  headache, 
vertigo,  coma. 

Meningitis  of  the  Convexity  of  the  Brain. — Head- 
ache, Jacksonian  epilepsy,  and  localized  cortical  paralyses  in- 
dicate the  site  of  the  lesion.  Melancholia  and  mania  are  often 
associated  with  diffuse  lesions  of  the  cortical  meninges. 

Prognosis. — The  statistical  prognosis,  as  I  have  found  it, 
has  already  been  given  (page  368).  But  these  bare  figures 
require  interpretation.  If  taken  in  time,  syphilis  of  the  nerv- 
ous system,  however  grave,  however  fulminating,  may  often 
be  controlled  and  actually  cured,  so  that  no  trace  of  it  remains. 


SYMPTOMS  383 

The  wildest  mania,  the  deepest  coma,  the  most  complete  paraly- 
sis may  yield  like  magic  to  prompt  and  efficient  treatment. 
Medicine  can  boast  no  miracle  greater  than  the  effect  of  mer- 
cury and  iodids  upon  syphilis  of  the  nervous  system.  The 
blind  see,  the  lame  walk,  the  deaf  hear,  and  those  who  are 
given  up  for  dead  arise  again  (cf.  Case  XXXIV). 

But  such  wonders  cannot  always  be  accomplished  even  by 
prompt  and  efficient  treatment.  If  the  lesion  is  a  diffuse  syphi- 
litic arteritis  the  impairment  to  circulation  (and  to  function) 
is  in  large  part  permanent  when  the  patient  first  consults  his 
physician.  And  in  any  case,  if  treatment  is  delayed  until  the 
nerves  have  degenerated  and  muscles  atrophied,  it  is  vain  to 
ask  of  any  treatment  the  real  miracle  that  would  be  required  to 
restore  the  patient  to  perfect  health.  Much  may  still  be  done 
to  prevent  further  destruction,  and,  even  after  months  of 
neglect,  the  sight  may  be  in  some  measure  restored  to  an  eye, 
the  strength  to  a  limb;  but  perfect  restoration  may  not  be 
looked  for. 

On  the  other  hand,  an  occasional  case  goes  from  bad  to 
worse  in  spite  of  our  best  efforts.  We  are  not  infallible  (Cases 
VII,  XXXII,  XXXIV). 

Treatment. — At  the  onset  of  the  attack  the  treatment 
should  be  intensive  and  specific.  Mercury  is  to  be  given  by 
intramuscular  injection  and  at  a  maximum  dose.  lodid  is 
begini  at  ten  drops  (minims)  three  or  four  times  a  day,  and 
run  up  to  the  point  of  conquering  the  lesion  or  gravely  poison- 
ing the  patient.  By  such  a  course  the  patient  should  be  slightly 
salivated,  more  or  less  iodized,  and  much  improved  within 
three  weeks.     Specific  treatment  is  then  stopped. 

The  severity  of  this  first  course  may  be  tempered  some- 
what according  to  circumstances.  Undue  sensitiveness  may 
bid  us  substitute  fumigations  or  inunctions  for  injections;  a 
delicate  digestion  may  forbid  too  vigorous  use  of  iodids. 
Prudence  in  the  use  of  mercury  is  surely  profilable,  for  severe 


384  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

salivation  always  does  harm;  but  prudence  in  the  use  of  iodids 
in  severe  cases  may  lead  to  failure.  If  the  emergency  is  great 
the  patient  may  be  severely  (but  briefly)  iodized  with  benefit. 

The  routine  of  rest,  light  diet,  and  urinary  analysis  need 
not  be  repeated  here  (page  198). 

After  these  first  zueeks  all  specific  medication  should  be 
stopped,  and  a  course  of  hygiene  instituted.  If  the  patient 
lives  in  the  city  he  should  sojourn  in  the  country,  live  on  the 
most  nourishing  diet  possible,  spend  his  days  in  the  open  air, 
and  take  an  iron  tonic  to  which,  in  some  cases,  the  addition  of 
strychnin  sulph.,  gr.  -^,  t.i.d.,  is  useful. 

This  hygienic  course  should  last  about  three  weeks,  and 
then  be  interrupted  by  a  second  course  of  specifics.  By  this 
time  the  patient  has  usually  greatly  improved,  and,  accord- 
ingly, the  specific  course  may  be  a  mild  one.  If  he  has  been 
salivated,  one  must  omit  the  mercury  altogether.  The  iodid 
need  rarely  be  increased  above  15  to  25  minims  (i  to  1.5  gm.). 

Thus  the  treatment  is  continued  in  interrupted  short 
courses,  alternating  hygiene  with  specifics  until,  at  the  end 
of  the  second  or  third  course  of  specifics,  the  patient  has 
obtained  the  maximum  benefit. 

The  reason  for  this  interrupted  method  of  treatment  has 
already  been  given  (page  141), 

If  the  patient  is  not  entirely  cured,  it  is  highly  probable 
that  the  remains  of  his  trouble  are  irremediable,  and  it  is, 
therefore,  vain  to  inundate  him  with  specifics.  But,  if  the 
symptoms  continue  to  show  real  activity  (or  if  the  patient  is 
unable  to  take  adequate  treatment  in  the  first  place),  he  may 
be  sent  to  Arkansas  or  to  Aix. 

But  this  is  not  all.  After  the  attack  has  been  relieved  every 
effort  must  be  made  to  prevent  relapse.  The  patient  must  be 
put  on  a  routine  preventive  course  (page  158)  and  carefully 
watched  for  evidence  of  relapse  of  any  kind.  The  cases  cited 
in  the  following  chapter  illustrate  the  difficulty  here  encoun- 


SYMPTOMS  385 

tered.  The  patient's  mind  is  often — very  often — just  enough 
disordered  to  induce  a  false  sense  of  security.  He  may  con- 
sider his  attacks  of  some  importance,  but  once  these  are  con- 
trolled he  has  no  further  care,  no  fear  for  the  future,  and  not 
the  least  wish  to  submit  to  repeated  and  prolonged  courses  of 
treatment.  One  must  always  be  prepared  for  this  mental  con- 
dition, and  ready  to  assume  a  high-handed  mastery  of  the 
situation. 

//  the  patient  is  first  seen  after  his  symptoms  have  existed 
for  some  time  his  history  should  be  carefully  investigated  in 
reference  to  treatment.  In  many  instances  it  will  be  found 
that  he  has  been  sadly  mishandled  and  perhaps  irretrievably 
harmed  by  prolonged  and  excessive  specific  medication.  In 
such  a  case  mercury  and  the  iodids  must  be  absolutely  prohib- 
ited for  a  time,  at  least,  however  much  the  patient  may  long 
to  continue  wallowing  in  them. 

But  if  he  has  been  inefficiently  treated,  or  if  he  is  suffer- 
ing from  some  acute  relapse,  the  specific  treatment  may  be 
resumed  in  short  courses,  but  should  usually  be  employed  with 
much  less  vigor  than  in  a  fresh  case. 

In  these  chronic  and  long-standing  cases,  hygiene,  hydro- 
therapy, mechanotherapy,  and  electricity — in  fact,  all  the  re- 
sources of  neurology — are  far  more  to  the  point  than  mercury 
and  iodid. 

Operative  Treatment. — Quite  a  number  of  cases  of 
brain  gumma  have  been  subjected  to  operation.  Stransky,^ 
in  a  recent  review,  concludes  that  it  is  quite  justifiable  if  prompt 
relief  does  not  result  from  specific  treatment.  But  it  is  open 
to  question  whether  the  operative  results  as  yet  justify  such  an 
opinion. 

*  Centralhl.  j.  d.  Crenzgebieie,  1905,  vol.  viii,  p.  i. 


CHAPTER    XXVI 
SYPHILIS  OF   THE  NERVOUS  SYSTEM  "^ 

CLINICAL    TYPES:    DIAGNOSIS 

Despite  the  utter  irregularity  of  the  symptoms  of  syphiHs 
of  the  nervous  system,  there  are  certain  recognizable  types  to 
which  a  case,  for  a  time,  at  least,  usually  adheres. 

We  may  distinguish  : 

Syphilitic  paralysis. 

Ocular  paralyses. 

Hemiplegia  and  apoplexy. 

Aphasia. 

Deafness. 

Facial  paralysis. 

Other  forms  of  paralysis. 
Syphilitic  epilepsy. 
Syphilitic  insanity. 
Syphilis  of  the  spinal  cord. 
Parasyphilids. 

Tabes. 

Paresis. 

Erb's  spastic  spinal  syphilis. 
Syphilitic  neuritis. 

OCULAR    PARALYSES 

One  hundred  and  seventeen  cases,  of  which  63  involved  the 
motor  oculi  (8  bilateral),  34  the  optic  (neuritis)   (6  bilateral), 

» Reviewed  by  Dr.  E.  G.  Zabriskie. 
386 


OCULAR    PARALYSES  387 

14  the  sixth  (i  bilateral).  In  only  a  few  cases  are  several 
ocular  nerves  recorded  as  simultaneously  or  successively  in- 
volved. The  right  eye  was  affected  28  times,  the  left  21  times, 
both  15  times.  Ten  cases  were  bilateral.  Both  eyes  were 
paralyzed  within  a  short  period  at  one,  three,  four,  five,  six, 
ten,  eighteen,  and  twenty-one  years.  Twice  the  eyes  were  in- 
volved successively  at  four  and  nine,  eighteen,  and  twenty 
years. 

The  ocular  lesions  were  associated  with  other  lesions  of 
the  nervous  system  in  85  cases ;  with  tabes  ^  23  times,  with 
hemi-  and  monoplegia  22  times,"  with  aphasia  and  auditory 
paralysis  each  9  times,  less  often  with  every  lesion  of  the  list. 

Paralysis  of  the  Motor  Oculi. — Paralysis  of  the  third 
cranial  nerve  is  almost  the  hall-mark  of  cerebral  syphilis,  so 
common  and  so  characteristic  is  it,  whether  occurring  alone  or 
in  connection  with  other  and  graver  lesions. 

The  subjective  symptoms  are  diplopia  and  ptosis.  The 
former  I  find  about  thrice  as  common  as  the  latter.  There  is 
no  pain  unless  from  eye  strain.  Because  of  the  difficulty  in 
fixing  the  location  of  objects  the  gait  may  be  uncertain  and 
there  may  be  vertigo  (14  cases). 

Examination  reveals  some  or  all  of  the  following  changes, 
depending  upon  the  more  or  less  complete  paralysis  of  the 
nerve. 

1.  Ptosis. — This  is  usually  complete  and  hides  the  ocular 
deviation.     On  lifting  the  lid  we  find : 

2.  Deviation  of  the  Eye.- — The  eye  is  drawn  outward  by 
the  action  of  the  external  rectus  and  the  superior  oblique 
muscle. 

If  the  paralysis  is  partial,  afifecting  only  certain  of  the 
muscles  innervated  by  the  motor  oculi,  the  eye  is  fixed  in  vari- 
ous positions  according  to  the  muscles  paralyzed. 

*  Exclusive  of  the  changes  in  pupillary  reaction. 
2  And  probably  oftener. 
27 


388  SYPHILIS   OF   THE   NERVOUS   SYSTEM 

3.  Fixation  of  the  Eye. — The  eye  is  almost  immobile,  and 
can  be  moved  only  slightly  in  the  direction  of  the  unparalyzed 
muscles. 

4.  Diplopia.- — The  usual  type  of  diplopia  is  crossed  with 
the  false  image  slightly  elevated  and  inclined  away  from  the 
paralyzed  eye.  Incomplete  or  complex  paralyses  vary  the  rela- 
tive positions  of  the  image  as  they  do  that  of  the  eye  itself. 

5.  Mydriasis  {Internal  Ophthalmoplegia). — This  is  due  to 
paralysis  of  the  sphincter  iridis  and  the  ciliary  muscle.  As  a 
result  the  patient  finds  it  impossible  to  read,  though  the  sight 
at  distance  is  relatively  little  affected. 

Paralysis  of  the  Abducens. — The  only  subjective  symptom 
is  diplopia,  which  examination  reveals  to  be  homonymous  and 
with  both  images  erect  and  at  the  same  elevation.  The  eye  is 
fixed  in  internal  strabismus. 

Paralysis  of  the  Fourth  Nerve. — Extremely  rare :  homony- 
mous diplopia  with  the  false  image  below  the  true  and  inclined 
obliquely.     The  eye  is  raised  and  turned  inward. 

Optic  Neuritis. — Next  in  frequency  to  paralysis  of  the 
motor  oculi.  This  lesion  is  so  intimately  related  with  visible 
disturbances  within  the  eye  that  it  is  better  to  consider  it  in 
relation  to  these  (page  419). 

Site  of  the  Lesion. — Extension  to  the  nerves  of  syphilitic 
lesions  in  the  hones  of  the  orbit  is  very  rare,  and  is  accom- 
panied by  local  tenderness,  pain,  or  even  swelling.  All  the 
nerves  are  usually  involved.  Invasion  from  gumma  of  the 
sphenoidal  fissure  may,  according  to  Rochion-Duvigneaud,  be 
diagnosed  from  the  simultaneous  involvement  of  all  the  nerves 
that  pass  through  this  fissure:  viz.,  the  third,  the  fourth,  the 
first  branch  of  the  fifth,  and  the  sixth,  the  remaining  branches 
of  the  fifth  being  uninvolved.  The  optic  nerve  may  be  impli- 
cated. 

Excepting  the  optic,  these  nerves  are  very  little  subject  to 
syphilitic  neuritis. 


HEMIPLEGIA   AND   APOPLEXY  389 

Gummatous  meningitis  is  by  far  the  commonest  cause  of 
ocular  paralysis.  The  nerves  are  compressed  or  inflamed. 
There  are  usually  associated  lesions  of  mental,  paralytic,  or 
epileptic  sort. 

Finally,  the  nerves  may  be  assailed  at  their  origin 
zvithin  the  brain  by  disease  of  the  posterior  cerebral  ar- 
teries. 

It  has  been  supposed  that  partial  paralysis  of  the  motor 
oculi  must  be  due  to  cerebral  lesions.  But  autopsies  have 
abundantly  proven  that  it  is  as  often,  perhaps  oftener,  due  to 
basilar  mening-itis. 

Prognosis.  — Prompt  mixed  treatment,  of  moderate  sever- 
ity (administering  the  mercury  by  injection,  inunction,  or 
fumigation)  cures  almost  all  syphilitic  paralyses  of  the  exter- 
nal muscles  of  the  eye  in  six  to  eight  weeks.  The  internal 
muscles  yield  rather  more  slowly,  if  at  all. 

Relapses  among  my  cases  after  at  least  one  year  of  health 
are  recorded  eight  times  (intervals  of  one,  two  (twice),  three, 
four,  five,  twelve,  and  thirteen  years). 

HEMIPLEGIA    AND    APOPLEXY 

Eighty-nine  cases,  of  which  five  are  apoplexies  without 
paralysis,  and  of  the  remainder  about  two  thirds  paralysis 
without  and  one  third  paralysis  with  apoplexy  (though  in  few 
was  the  loss  of  consciousness  complete). 

Onset. — The  attack  is  preceded  by  prodromes  (page  378). 
The  onset  usually  occupies  several  hours,  perhaps  several  days ; 
beginning  without  loss  of  consciousness  by  a  slight  weakness 
of  one  limb,  which  gradually  steals  over  the  whole  side.  Thus 
a  woman  remarks  one  afternoon  that  her  husband  drags  his 
left  leg  in  walking,  though  he  himself  is  unconscious  of  this; 
the  next  morning  he  awakes  with  left  hemiplegia  (see  also 
Case  XXXII). 


39©  SYPHILIS   OF   THE   NERVOUS    SYSTEM 

On  the  other  hand,  the  onset  may  be  sudden  and  complete, 
with  or  without  apoplexy. 

Finally,  syphilitic  apoplexy  may  be  the  severe  apoplexy 
characteristic  of  cerebral  hemorrhage,  lasting  for  hours  or 
days,  or  a  mere  fleeting  unconsciousness. 

Clinical  Type.  —  Syphilitic  hemiplegia  is  characterized  by 
incompleteness,  varying  intensity,  and  association  with  other 
lesions  of  the  nervous  system,  and  by  yielding  readily  to  treat- 
ment. 

Incompleteness. — Careful  examination  of  the  paralyzed 
limbs  reveals  that  the  muscles  are  very  unequally  involved. 
Certain  muscles  or  groups  of  muscles  are  weakened  rather  than 
absolutely  impotent.  Thus  the  face  is  often  but  little  affected, 
and  the  lower  extremity  may  retain  some  power  of  movement 
while  the  upper  is  completely  inert. 

Varying  Intensity. — But  more  striking  still  is  the  fact  that, 
if  the  exact  condition  is  noted  carefully  at  the  onset,  a  second 
examination  a  few  hours  later  reveals  many  minor  changes. 
While  one  limb  has  perhaps  gained  strength  another  may  have 
become  paralyzed,  or  perhaps  the  paralysis  has  everywhere 
progressed  or  everywhere  diminished.  Or  the  two  may  alter- 
nate in  a  "  recurrent  "  paralysis.  I  have  seen  a  patient  remain 
completely  hemiplegic  for  three  hours,  and  then  rapidly  and 
spontaneously  regain  his  strength.  (Such  a  condition  is  un- 
doubtedly due  to  vascular  spasm. ) 

Such  variations,  however,  are  exceptional.  Usually  one 
must  watch  sharply  to  note  the  variations  after  the  first  few 
hours,  unless  these  be  due  to  other  lesions  of  the  nervous 
system. 

Other  Lesions. — Hemiplegia,  like  any  other  of  the  clinical 
types  of  syphilis  of  the  nervous  system,  may  stand  alone  or 
may  be  but  one  of  many  lesions.  Even  if  unique,  as  is  so 
often  the  case,  it  is  not  absolutely  so.  We  have  studied  the 
warnings  that  precede  it.     Similar  phenomena  usually  accom- 


HEMIPLEGIA   AND   APOPLEXY  391 

pany  it:  viz.,  psychic  or  intellectual  disturbances,  vertiginous 
or  epileptiform  seizures,  outlying  or  discordant  paralyses.^ 
Among  these  latter,  aphasia,  dimness  of  vision,  and  paralysis 
of  the  motor  oculi  are  common. 

As  examples  of  crossed  paralyses  I  may  mention  a  case 
of  right  hemiplegia  and  left  ptosis  and  one  of  right  facial  paral- 
ysis, followed  a  year  later  by  left  hemiplegia.  The  ensuing 
two  cases  of  double  hemiplegia  merit  more  extended  mention 
as  examples  of  what  untreated  syphilis  of  the  nervous  system 
can  do. 

Case  XXXII. — H.  W.,  aged  thirty-two,  reports  that,  twelve 
years  before,  he  had  four  genital  sores,  followed  by  suppurating 
bubo,  indefinite  secondary  symptoms,  and  four  or  five  months' 
internal  mercurial  treatment.  Since  then  no  symptoms  until  five 
months  ago,  when  he  began  to  have  severe  headaches,  much 
worse  at  night.  He  has  lost  appetite  and  sleep,  and  has  sciatica, 
worse  at  night.     He  gives  no  alcoholic  history. 

Examination  reveals  diffuse  thickening  of  the  inner  half  of 
the  right  clavicle,  and  slight  thickening  with  crackling  on  pres- 
sure of  the  inner  half  of  the  left.  He  had  not  discovered  these 
lesions.  The  right  side  of  the  cranium,  the  clavicle,  the  shins, 
and  a  rib  on  the  left  side  are  tender. 

He  was  put  upon  mixed  treatment,  under  which  his  pains 
promptly  disappeared,  and  he  continued 'the  treatment  but  five 
months. 

Five  years  later,  while  dining  at  a  restaurant,  in  his  usual 
health,  he  discovered  that  he  had  lost  the  power  of  speech.  Much 
alarmed,  he  endeavored  to  rise,  but  found  the  left  side  helpless. 
His  companions  thought  him  drunk,  and  took  him  home  to  bed. 
After  a  few  hours  he  regained  all  his  faculties,  and  though  he 
has  had  several  similar  relapses  since,  none  have  been  as  sharp 
as  the  first. 

Examination  reveals  dilatation  of  the  right  pupil,  tenderness 
of  both  shins  and  of  the  ribs.     No  paralysis  apparent. 

He  was  put  upon  mixed  treatment  again,  and  was  not  seen 
until  two  months  later,  when,  without  warning  and  without  loss 

1  Hemianesthesia  is  unusual. 


392  SYPHILIS   OF   THE   NERVOUS   SYSTEM 

of  consciousness,  he  had  a  spasmodic  attack  in  the  right  side, 
followed  by  diplopia  and  partial  paralysis  of  the  rigJit  leg,  the 
left  remaining  unaffected. 

Examination  reveals  great  weakness  of  the  right  leg,  but  no 
complete  paralysis.  Arms  and  face,  rectum  and  bladder  normal. 
Slight  converging  strabismus  of  the  right  eye ;  pupil  normal ; 
mydriasis  of  the  left  eye. 

He  again  took  treatment  irregularly  and  inefficiently,  and,  a 
month  later,  these  lesions  having  been  only  partially  relieved,  his 
mind  was  markedly  impaired,  his  memory  defective,  and  he  had 
another  attack  of  paralysis  in  the  right  leg. 

He  was  then  taken  in  hand  and  given  fifteen  grains  of  iodid 
three  times  a  day.  In  four  weeks  he  was  apparently  well.  He 
continued  taking  the  iodid  for  six  months,  and  ,y/.r  months  there- 
after had  another  left  hemiplegia  without  headache  or  loss  of 
consciousness ;  but  this  time  his  mental  and  physical  condition 
was  extremely  unpromising,  and  it  is  probable  that  he  died 
soon  after. 

Case  XXXIII. — W.  H.,  aged  thirty-seven.  Was  first  seen 
lying  senseless  and  almost  motionless  at  his  home.  From  his 
friends,  and  subsequently  from  himself,  the  following  history 
was  obtained : 

Chancre  and  a  few  early  symptoms  seven  years  before ;  treat- 
ment by  mercury  six  months.  Three  years  later,  left  hemiplegia 
and  aphasia,  followed  by  various  ulcerations  and  periostitis  of 
the  external  condyle  ©f  the  left  femur.  He  was  treated  irregu- 
larly and  inefficiently  for  four  years,  during  which  time  he  had 
two  more  attacks  of  aphasia ;  then  the  present  attack  came  on. 

He  arrived  home  at  eleven  o'clock  completely  aphasic,  and 
then  gradually  went  into  a  state  of  almost  complete  unconscious- 
ness. His  pupils  both  reacted  to  light,  but  were  unequal.  The 
only  evidence  of  intelligence  he  gave  was  to  shake  or  nod  his 
head  when  questioned.  There  were  several  active  ulcerations 
over  the  body  and  many  circular  pigmented  scars.  The  urine 
was  of  a  specific  gravity  of  1.040,  loaded  with  urates,  and  con- 
tained albumin  and  casts.  The  right  arm  and  leg  were  partially 
paralyzed. 

He  was  given  ten  grains  of  potassium  iodid  every  three  hours. 
During  the  dav  he  came  out  of  his  letharg^•  and  went  into  an 


HEMIPLEGIA   AND   APOPLEXY 


393 


active  delirium.  That  night  he  did  not  sleep,  and  the  next  day- 
he  became  maniacal. 

Mercurial  inunctions  were  begun.  The  mania  began  to  lessen 
on  the  second  day,  and  on  the  third  he  slept  ten  hours,  and  was 
fairly  quiet  and  rational  most  of  the  time.  On  the  eleventh  day 
he  was  dressed  and  walking  about,  his  hemiplegia  much  im- 
proved, his  mind  almost  normal.  He  was  taking  about  one  hun- 
dred grains  of  iodid  a  day.  This  was  rapidly  diminished,  and 
he  continued  to  improve.  A  month  from  the  beginning  of 
the  attack  he  was  entirely  well,  except  for  slight  slowness  of 
thought  and  articulation ;  slight  weakness  on  the  left  side  and 
a  severe  bronchitis. 

After  this  he  was  seen  no  further  for  a  month,  when  he  sud- 
denly relapsed  into  his  condition  of  stupor  and  paralysis.  This 
improved  for  a  day  or  two,  and  again  gave  place  to  mania,  and, 
on  the  fourth  day  of  the  attack,  his  right  arm  and  leg  became 
paralyzed,  the  onset  of  the  attack  being  preceded  by  a  slight 
convulsion.  His  right  pupil  was  dilated,  his  intellect  very  con- 
fused. The  right  side  was  completely  paralyzed,  as  was  the 
bladder. 

He  was  promptly  put  upon  loo  grains  of  iodid  a  day ;  but, 
in  spite  of  this,  five  days  later  he  had  a  sharp  epileptic  fit,  fol- 
lowed by  severe  pain  in  the  head ;  but  the  following  day  the 
paralysis  in  the  right  hand  had  disappeared. 

Inunctions  and  iodid,  at  the  dose  of  a  dram  a  day,  were  con- 
tinued for  several  weeks,  the  patient  constantly  improving. 

At  the  end  of  a  month  from  the  last  attack  he  had  three  con- 
vulsive spasms  in  his  right  hand,  and  became  aphasic  again,  and 
very  depressed,  but  not  stupid. 

No  paralysis  accompanied  this  attack,  and  he  again  improved 
steadily  under  treatment,  until  one  month  later — four  months 
after  he  was  first  seen — he  had  another  general  epileptic  attack, 
followed  by  acute  mania  and  rapidly  progressing  debility. 

In  this  attack  he  died  in  two  weeks. 


Such  cases  require  no  comment.  They  show  the  full  pic- 
ture of  cerebral  syphilis;  the  sudden  onset  of  the  most  diverse 
symptoms ;  the  marvelous  effect  of  treatment  in  relieving  these ; 


394  ■    SYPHILIS    OF    THE    NERVOUS    SYSTEM 

the  unreasoning  carelessness  and  confidence  of  the  patient ;  the 
inevitable  relapse  of  the  case  that  has  been  for  years  irregularly 
treated ;  the  final  fatal  issue. 

Prognosis. — To  find  such  cases  in  a  record  of  private 
practice  I  had  to  look  back  thirty  years.  Syphilis  of  the  nerv- 
ous system  we  still  constantly  see,  but  these  ill-treated,  poorly 
nourished,  alcoholic  victims  appear  only  in  our  city  hospitals. 
In  private  we  encounter  every  lesion,  perhaps  every  combina- 
tion of  symptoms,  but  very  rarely,  as  in  the  above  instances, 
all  symptoms  in  one  case. 

The  well-treated  case  of  syphilitic  hemiplegia  usually  re- 
covers rapidly,  leaving  little  weakness.  Be  the  underlying 
lesion  a  meningitis,  or  a  thrombosis,  or  simply  a  syphilitic 
arteritis  (the  common  lesion),  it  yields  kindly  to  mixed  treat- 
ment. 

Under  two  circumstances,  however,  a  cure  may  not  be 
obtained : 

1.  If  the  artery  ruptures,  the  paralysis,  due  to  cerebral 
hemorrhage,  is  no  better  in  prognosis  than  any  non-syphilitic 
apoplexy. 

2.  If  the  case  is  neglected  until  the  paralyzed  muscles 
atrophy,  or  the  arterial  or  meningeal  exudate  becomes  organ- 
ized, permanent  paralysis  becomes  inevitable. 

It  is  surprising,  to  be  sure,  how  slow  these  changes  are 
to  occur,  and  how  many  years  the  patient  may  remain  in  some 
degree  amenable  to  mixed  treatment ;  but  it  is  only  one  degree 
less  marvelous  to  find  a  patient  to  whom  the  highest  possible 
doses  of  iodid  and  mercury  have  been  administered  in  vain, 
keeping  himself  poisoned  with  these  drugs  year  in  and 
year  out  in  the  hope  that  they  will  ultimately  benefit  him. 
Yet  such  victims  of  misguided  enthusiasm  are  pitifully  nu- 
merous. •  , 


DEAFNESS  395 


APHASIA. 


Aphasia,  while  one  of  the  commonest  symptoms  of  cere- 
bral syphilis  (more  frequent  than  is  shown  in  my  statistics), 
rarely  stands  alone;  only  twice  in  my  series  was  it  not  at- 
tended, preceded,  or  followed  by  other  symptoms  of  cerebral 
syphilis. 

Syphilitic  aphasia  is  often  incomplete  and  intermittent.  It 
may  cease  spontaneously.  Agraphia,  word-blindness  and 
word-deafness  are  likely  to  be  associated  with  it. 

Nine  of  my  cases  of  aphasia  accompanied  hemiplegia  ^ 
(e.  g.,  Case  XXXII)  ;  epilepsy  and  ocular  paralyses  are  also 
frequent  concomitant  lesions. 

DEAFNESS ' 

Almost  half  the  cases  of  syphilitic  deafness  occur  in  the 
first  two  years  of  the  disease.^  While  the  deafness  may  be 
incomplete  or  may  assert  itself  insidiously,  the  typical  deaf- 
ness of  syphilis  is  sudden  and  absolute.  One  patient  related 
that,  at  a  given  moment,  without  any  warning,  he  was  stricken 
suddenly  and  absolutely  deaf  in  one  ear.  Others  stated  that 
the  deafness  became  absolute  within  an  hour  or  two. 

Pathology. — The  lesion  may  be  in  the  internal  ear  or  some- 
where along  the  course  of  the  nerve.  The  aurist  places  it  usu- 
ally in  the  inner  ear,  and  autopsy  has  several  times  revealed 
exudative  and  sclerotic  changes  therein,  together  with  syphi- 
litic exostoses.     None  of  these  changes  are  peculiar  to  syphilis. 

On  the  other  hand,  the  association  with  other  lesions  of 
cerebral  syphilis  in  our  cases  has  been  striking.  Only  thirty- 
one  per  cent  were  free  from  such  concomitant  lesions.     These 


1  Usually  but  not  always  on  the  right  side. 

2  Auditory  hyperesthesia  has  been  noted;  it  is  extremely  rare. 

3  Politzer  has  seen  a  case  in  the  first  week. 


396  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

were  many  ^  or  few.  The  eye  was  involved  9  times  (thrice 
with  the  ear,  6  times  before  or  after  it)  ;  other  paralyses 
occurred  5  times,  neuralgia  5  times,  tabes  thrice. 

Moreover,  severe  vertigo  was  only  four  times  noted  at  the 
onset  of  deafness-  (though  slight  vertigo  is  always  present). 

Hence  it  seems  proper  to  associate  deafness  with  lesions 
of  the  nervous  system  rather  than  with  those  of  the  ear. 

Symptoms. — The  onset  is  usually  zmthout  prodromes  (con- 
trary to  the  general  rule)  and  painless;  zvithin  a  few  hours  the 
patient  is  stone-deaf  in  one  ear  (rarely  in  both).  Slight  ver- 
tigo is  usually  present,  but  this  is  not  a  prominent  symptom. 
The  characteristics  are  suddenness  of  onset,  rapid  progress  of 
the  deafness,  and  loss  of  bone  conduction.^  But  these  three 
symptoms,  though  very  suggestive  of  syphilis,  if  they  occur  in 
a  person  under  forty-five  years  of  age,  are  not  absolutely 
pathognomonic. 

Prognosis.  —  Deafness  occurring  in  the  first  two  years  of 
the  disease  may  often  be  cured  if  attacked  promptly  by  in- 
jections or  inunctions  of  mercury  (I  prefer  the  former)  and 
iodid.* 

If  treatment  is  delayed  or  the  onset  of  deafness  is  late  in 
the  disease  the  prognosis  is  not  good. 

Treatment.. — The  only  special  treatment  for  deafness  is 
that  by  pilocarpin.  If  a  short,  sharp  course  of  mixed  treat- 
ment fails,  a  course  of  hypodermic  injections  of  pilocarpin 
hydrochlorate  should  be  instituted.  Using  a  two  per  cent 
solution,    daily    injections    should   be   given,,  beginning    with 

'  E.  g.,  hemiplegia  at  one  year;  paralysis  at  two  years;  demented  at  four; 
deaf  at  five;  deaf  at  two  years,  ocular  paralysis  at  four,  neuralgia  at  five,  paral- 
yzed vocal  cord  at  ten. 

^  Though  in  three  other  cases  it  is  noted  at  intervals  of  two,  six  (preceding), 
and  eight  years  from  the  deafness. 

2  Tested  by  holding  a  tuning  fork  against  the  teeth. 

*  Of  15  cases  followed,  7  were  cured,  4  somewhat  improved,  and  4  un- 
improved; of  the  7  cures,  5  were  obtained  in  the  first  two  years  of  the  disease. 


OTHER    FORMS    OF    PARALYSIS  397 

TTliv,  and  increasing  one  minim  at  each  dose  for  a  week;  con- 
tinue the  daily  dose  at  or  about  iTtxij  for  another  week.  Po- 
htzer  advises  employing  this  treatment  before  the  antisyphi- 

litics. 

FACIAL    PARALYSIS 

The  only  peculiarity  to  distinguish  facial  paralyses  from 
similar  lesions  due  to  other  causes  is  the  concurrence  of  other 
syphilitic  lesions  and  the  amenability  to  antisyphilitic  treat- 
ment. 

When  it  occurs  in  the  first  year  of  the  disease  it  is  rarely 
(one  in  five  of  my  cases)  accompanied  by  any  other  lesion  in 
the  nervous  system,  though  such  lesions  often  (three  cases) 
follow  in  later  years. 

Facial  paralysis  is  usually  incomplete,  whether  syphilitic 
or  not. 

The  prognosis  is  relatively  good;  some  improvement  is 
almost  always  obtained. 

OTHER   FORMS   OF    PARALYSIS 

Since  any  nefve  or  any  combination  of  nerves  may  be  par- 
alyzed by  syphilis,  it  were  futile  to  attempt  the  enumeration 
of  all  the  forms  or  combinations  of  syphilitic  paralysis. 

Besides  the  thirteen  monoplegias  and  irregular  paralyses 
of  the  extremities  and  the  laryngeal  paralyses  mentioned  in  the 
table  on  page  372,  one  case  of  olfactory  and  three  of  glosso- 
pharyngeal paralyses  have  been  noted. 

Acute  bulbar  paralysis,  due  to  rupture  or  thrombosis  of  the 
basilar  artery,  causes  apoplexy  followed  by  Cheyne-Stokes's 
respiration  or  epileptiform  attacks.  If  death  is  not  immediate 
there  follow  labio-glosso-laryngeal  paralysis,  more  or  less 
complete  paralysis  of  all  the  extremities,  and  various  respira- 
tory and  cardiac  irregularities.     Albuminuria,  glycosuria,  and 


398  SYPHILIS    OF   THE    NERVOUS    SYSTEM 

hyperpyrexia  may  also  coexist  and  the  patient  soon  dies.    The 
condition  is  an  extremely  rare  one. 


SYPHILITIC    EPILEPSY 

The  epilepsy  of  syphilis,  if  one  includes  every  convulsive 
phenomenon  under  this  head,  is  extreinely  common.  A  transi- 
tory and  Jacksonian  epileptiform  attack  accompanies  the  ma- 
jority of  paralytic  or  vertiginous  seizures,  but  marked  or  per- 
sistent attacks  of  grand  mal  are  relatively  uncommon.  It  is 
often  associated  with  mania  (5  cases  ^),  dementia  (3  cases  ^), 
or  ocular  paralysis  (6  cases).  Indeed,  neurologists  consider 
syphilitic  epilepsy  to  be  commonly  a  symptom  or  prodrome  of 
paresis. 

Grand  MaL — Syphilitic  grand  mal  differs  from  the  idio- 
pathic type  in  four  particulars  : 

1.  It  begins  in  adult  life  instead  of  in  childhood. 

2.  The  aura  and  initial  cry  are  often  absent. 

3.  There  is  usually  history  or  other  evidence  of  syphilis. 

4.  The  epilepsy  yields  to  antisyphilitic  treatment. 
Otherwise  there  is  nothing  to  distinguish  them. 

Petit  Mal. — Uncommon.  Age,  history,  and  treatment 
alone  distinguish  it. 

Jacksonian  Epilepsy. — Localized  convulsive  seizures  are 
almost  exclusively  due  to  syphilis  or  trauma,  and  are  almost 
always  associated  with  paralysis  of  the  affected  nerves. 

SYPHILITIC    INSANITY 

Insanity,  like  epilepsy,  is  far  more  frequent  than  my  rec- 
ords show ;  for  a  brief  dementia  or  mania  often  accompanies 
the  onset  of  some  other  lesion;  e.  g.,  hemiplegia,  but  is  over- 

*  One  duplicate. 


SYPHILITIC    INSANITY  399 

shadowed  by  it,  while  mental  inefficiency,  impairment  of  mem- 
ory, and  loss  of  emotional  control  precede  and  follow  almost 
every  grave  paralytic  attack, 

Berkley  ^  states  that  syphilitic  insanity  depends  rather  upon 
the  tissue  starvation  and  congestion  due  to  vascular  disease 
than  upon  the  meningeal  processes. 

The  prodromes  are  nocturnal  headache,  "  fleeting  pareses 
and  paralyses,  epileptiform  convulsions,  sudden  faints,  abrupt 
attacks  of  furibund  mania,  followed  by  half  comatose  condi- 
tions. .  .  .  The  pupillary  symptoms,  though  not  so  frequent 
as  the  pareses,  are  of  the  same  order ;  also  irregularities  in  the 
size  of  the  pupils  and  mydriasis  are  more  often  met  with  than 
spastic  myosis." 

The  following  is  Berkley's  classification : 

1.  Sudden  furibund  delirium  of  short  duration,  followed 
by  half  comatose  states. 

2.  Delusional  insanity. 

3.  Slowly  progressive  dementia,  attended  by  incomplete 
paralysis  of  the  extremities  and  external  ocular  muscles. 

4.  Dementia,  attended  not  by  paresis,  but  by  epileptiform 
attacks. 

5.  Syphilitic  epilepsy. 

Mania. —  A  neglected  and  fatal  case  in  which  mania  was  a 
prominent  symptom  has  already  been  cited  (Case  XXXIII). 
In  this  instance  the  brilliancy  of  the  temporary  reaction  to 
treatment  was  overmatched  by  persistent  neglect,  and  the  issue 
was  fatal.  But  only  three  other  maniacal  cases  died  under 
our  care,  while  at  least  four  were  promptly  and  perfectly 
cured.    The  others  (five)  remained  feeble-minded  or  demented. 

Delusional  Insanity.— "  Found  especially  in  persons  who 
have  inherited  a  strong  predisposition  to  insanity,  and  may 
closely    simulate   paranoia.      The   delusions   are    varied.  .  .  . 

1  "Mental  Diseases,"  D.  Appleton,  1900. 


400  SYPHILIS   OF   THE   NERVOUS   SYSTEM 

Aural  hallucinations  are  rare.  .  .  .  Treatment  is  ineffectual, 
the  lesions  being  organic  and  permanent." 

Thus  Berkley :  the  syphilologist  sees  such  cases  chiefly 
under  the  guise  of  melancholia.  It  is  important  to  remember 
that  sexual,  alcoholic,  and  other  excesses  may  lead  to  this  con- 
dition quite  as  definitely  as  does  syphilis.  Indeed,  the  few  cases 
of  delusional  insanity  which  I  have  seen  follow  upon  syphilis 
have  seemed  to  be  due  rather  to  alcoholism  than  to  the  disease. 

On  the  other  hand,  one  should  not  take  the  incurability 
of  such  cases  too  seriously.  It  is  impossible  always  to  deter- 
mine that  the  lesion  is  organic;  the  test  course  should,  there- 
fore, always  be  tried. 

Progressive  Dementia  with  Paralysis.— The  two  cases  of 
bilateral  hemiplegia  cited  above  are  of  this  class.  Indeed,  most 
neglected  hemiplegias  of  syphilitic  origin  seem  to  lead  to  in- 
sanity. But  such  insanity  is  by  no  means  always  fatal — wit- 
ness the  following  case,  which  illustrates,  moreover,  the  impor- 
tant fact  that  symptoms  of  cerebral  syphilis  may  disappear 
without  specific  treatment : 

Case  XXXIV. — J.  W.,  a  physician,  aged  thirty,  when  first 
seen,  in  September,  1871,  gave  the  following  history: 

August,  1870. — Chancre  of  left  index  finger.  Took  mercury. 
No  secondaries  noted. 

January,  1871. — Squamous  lesions  of  hands  and  face,  iritis, 
fever,  and  nocturnal  headache.  Later,  "  ulcerated  sore  throat 
and  blotches  on  genitals."     Continued  mercury. 

May,  1871. — Began  potassium  iodid  (0.5  gm.  t.i.d.),  and  the 
headache,  which  had  become  intolerable,  was  promptly  amelio- 
rated, but  did  not  disappear. 

June,  1 87 1. — While  continuing  iodid  the  headache  became 
much  worse,  and  ten  days  later,  while  starting  on  a  journey,  he 
was  seized  with  vertigo  and  vomited  his  breakfast.  He,  never- 
theless, boarded  his  train ;  but  as  he  seated  himself  was  surprised 
to  find  he  could  not  put  his  left  hand  in  his  pocket.  Alarmed, 
he  attempted  to  leave  his  seat,  but  fell,  on  account  of  paralysis 


SYPHILITIC    INSANITY 


401 


of  his  left  leg-.  He  was  helped  from  the  train,  had  another  vio- 
lent attack  of  vomiting  lasting-  half  an  hour  (during  which  time 
he  noticed  paralysis  of  his  face  and  tongue),  and  then,  his  paral- 
ysis in  great  measure  relieved,  walked  half  a  mile  to  a  ferry- 
boat. After  the  attack  the  headache  was  much  less  severe, 
and  the  paralysis  almost  entirely  disappeared  in  the  course  of 
a  week. 

August,  1 87 1. — Increased  iodid  to  4  gm.  a  day  for  a  few 
weeks ;  then  went  to  the  country.  Headache  promptly  left  him, 
though  he  stopped  all  medicines. 

September,  1 871. —Headache  has  relapsed.  Consults  Dr. 
Keyes,  Sr.  The  patient  is  unduly  emotional,  but  intellectually 
apathetic  and  slow.  Still  slightly  weak  on  left  side,  and  face  is 
somewhat  drawn  to  right.  His  memory  is  defective.  Any  at- 
tempt to  study  makes  his  head  feel  "  queer."  His  sexual  desire 
is  greatly  diminished.  Urinates  thrice  at  night. — He  is  ordered  to 
resume  iodid  at  4  gm.,  and  to  return  to  the  country, 

October  3d. — Back  to  town.  Stopped  iodid  after  two  weeks 
(indigestion).  Headache  worse,  slight  internal  strabismus  of 
right  eye  (intermittent),  mental  condition  still  unsatisfactory, 
left  leg  weak. — Inunctions :  sodium  iodid  i  gm.  t.i.d. 

December  15th. — Much  improved.  Has  continued  iodid  and 
rubs,  and  is  just  salivated:  stop.  The  eye  is  normal,  the  mental 
condition  satisfactory,  the  leg  stronger.  But  the  headache,  which 
had  disappeared,  has  relapsed  during  the  last  few  nights. 

January,  1872. — Relapse  of  headache  with  internal  strabismus 
of  left  eye.  "  Mentally  unsteady  and  greatly  depressed." — Re- 
sume treatment. 

September,  1873. — His  symptoms  were  promptly  relieved  and 
he  neglected  treatment.  After  ten  days  of  diarrhea  he  passed 
gradually  into  a  comatose  condition.  He  could  neither  speak 
himself  nor  understand  others ;  he  could  not  so  much  as  raise 
his  hand;  he  was  delirious  at  times;  the  bladder  was  paralyzed, 
the  bowel  inactive.  He  was  at  this  time  under  the  care  of  a 
Dr.  P.,  who  prophesied  his  early  demise,  and  gave  no  specifics. 
Yet  after  a  month  his  condition  began  to  improve,  until  on — 

December  20,  1873. — Having  been  out  of  the  house  two  or 
three  times,  he  relapsed  (without  diarrhea)  into  a  stuporous  con- 
dition, somewhat  less  than  before,  but  sufficient  to  keep  him  in 


402  SYPHILIS   OF   THE    NERVOUS   SYSTEM 

bed  six  weeks.  Then  again  he  began  to  mend  without  the 
aid  of  mercury  or  iodid,  and  in  three  months  was  able  to  get 
about. 

June  17,  1874. — Returns  to  Dr.  K.,  having  taken  no  specifics 
whatever.  He  is  improving  rapidly  and  has  gained  forty  pounds 
in  the  past  year.  His  intellect  is  quite  clear,  his  bladder  sound ; 
he  looks  very  well,  but  has  static  ataxia  and  mydriasis,  and  his 
head  is  beginning  to  ache  again.  He  is  still  a  little  emotional ; 
his  memory  is  good,  his  capacity  for  work  fair. 

A  child  born  to  him  eighteen  months  ago  is  fat  and  well; 
wife  not  infected. — Resume  treatment. 

October  3,  1878. — Has  taken  very  little  treatment.  He  soon 
became,  and  has  remained,  absolutely  well.  He  now  has  an  ulcer 
of  the  pharynx  which  does  not  yield  to  bichlorid,  gr.  tV>  t-i-d. 
He  can  now  take  no  iodid  in  any  form  except  tr.  iodi;  under 
this  and  local  treatment  the  ulcer  promptly  heals. 

1 88 1. — Node  on  sternal  end  of  clavicle  "  as  big  as  a  pul- 
let's egg."  Slight  static  ataxia. — Soon  relieved  by  tr.  iodi  and 
bichlorid. 

1895,  1898,  1899. — He  reports  entirely  well  but  for  a  little 
dyspepsia.     His  urine  is  normal ;  his  daughter  sound. 

April,  1900. — Left  hemiplegia  without  loss  of  consciousness. 

March,  1901. — Reports  to  me.  He  has  taken  no  mercury  or 
iodid  since  1881.  He  retains  only  a  slight  limp  as  a  token  of  his 
hemiplegia.     Otherwise  in  perfect  health. 

November,  1906. — Condition  remains  the  same. 

It. is  to  be  noted  that  this  case,  like  the  two  previously  cited, 
may  be  used  as  illustrations  of  syphilitic  hemiplegia  or  syphi- 
litic insanity.  The  two  clinical  types  are  thus  inextricably  in- 
termingled in  many  instances,  the  one  predominating  at  one 
time,  the  other  at  another. 

Dementia  without  Paralysis. — Rare.  It  often  accompa- 
nies epilepsy,  as  noted  above. 

The  recorded  outcome  of  17  cases  of  insanity  (excluding 
mania  and  epilepsy)  w^as  8  "  cures,"  6  deaths,  and  3  unim- 
proved. This  proportion  of  cures  is  very  high,  and  was  possi- 
ble only  because  the  patients  were  seen  at  the  very  onset  of 


SYPHILIS   OF   THE    SPINAL   CORD  403 

the  attack.     Most  of  these  so-called  "  cures  "  were  doubtless 
only  temporary. 


SYPHILIS   OF   THE    SPINAL    CORD 

The  symptoms  of  syphilis  of  the  cord  are  more  irregular 
even  than  those  of  syphilis  of  the  brain. 

Not  only  are  the  meningeal  and  arterial  lesions  often  active 
over  various  regions  of  the  cord  at  once,  but  they  are  often 
associated  with  active  cerebral  lesions  as  well.  Hence  the 
clinical  picture  is  apt  to  be  very  confused.  Indeed,  syphilis 
imitates  every  disease  of  the  spinal  cord. 

The  chief  symptoms  of  syphilis  of  the  cord  are : 
Disturbance  of  the  reflexes. 
Loss  of  sexual  power. 
Pain,  anesthesia,  and  paresthesia. 
Paralysis  of  the  bladder  and  bowel. 
Paraplegia  and  other  paralyses. 
Ataxia. 

Ocular  symptoms. 
Trophic  disturbances. 
Disturbance  of  the  Reflexes. — Every  syphilitic  lesion 
of  the  cord  causes  some  disturbance  in  the  reflex  presided 
over  by  the  diseased  segment.  Inasmuch,  however,  as  syph- 
ilitic lesions  are  usually  disseminated,  the  most  superficial 
examination  often  suffices.  Loss  of  knee-jerk,  without  paral- 
ysis, suggests  tabes.  Exaggerated  knee-jerk  (often  asso- 
ciated with  ankle  clonus)  shows  a  break  in  the  association 
tracts. 

Meningeal  lesions  not  involving  the  cord  (rare)  may  cause 
no  reflex  disturbance. 

Loss  OF  Sexual  Power. — This  prodrome  of  syphilis  of 
the  nervous  system  is  peculiarly  common  and  severe  in  lesions 

of  the  cord. 
28 


404  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

Disturbances  of  Sensation. — Pain  is  due  to  meningeal 
lesions  or  to  tabes.  Arterial  lesions  of  the  cord  rarely  cause 
pain.  The  pain  ma)'  be  of  any  variety  or  may  affect  any  nerve. 
jMeningeal  pain  usually  shows  the  syphilitic  nocturnal  exacer- 
bation ;  tabetic  pain  does  not.  Tabetic  pain  is  intermittent 
and  sharp  or  stabbing  in  character.  It  is  usually  most  marked 
in  the  lower  extremities. 

Anesthesia  may  be  localized,  unilateral,  or  bilateral.  In 
tabes  there  is  often  a  band  of  anesthesia  to  touch  in  the  mid- 
thoracic  region,  which  may  be  associated  with  analgesia. 

Paresthesia  and  nuiubiiess  are  fairly  common  both  in  syphi- 
lis of  the  cord  and  in  tabes.  They  may  suggest  the  level  of  the 
lesion.  The  tabetic  usually  has  numb  feet  and  a  constricted 
"  girdle  sensation  "  at  the  thoracic  area  of  anesthesia. 

Paralysis  of  Bladder  and  Bowel. — Retention  of  urine 
and  feces  or,  far  less  commonly,  inability  to  retain  the  dejecta, 
may  be  caused  by  a  lesion  in  the  sacral  portion  of  the  cord  or 
in  any  part  of  the  motor  tract  above.  Clinically,  obstinate 
constipation  and  more  or  less  complete  retention  of  urine  are 
among  the  commonest,  the  earliest,  the  most  persistent,  and 
the  most  threatening  effects  of  spinal  syphilis  and  tabes.  The 
necessary  catheterism  always  infects  the  bladder,  and,  if  the 
trophic  nerves  to  bladder  and  kidney  have  suft'ered,  these 
organs  fall  an  easy  prey  to  the  infection,  and  the  resulting 
pyelonephritis  may  prove  fatal.  Such  a  condition  must  be 
combated  by  urotropin,  systematic  catheterism,  and  vesical 
lavage. 

Paralysis. — Paraplegia,  spinal  hemiplegia  (Brown-Se- 
quard  type),  monoplegia,  and  various  irregular  paralyses  may 
occur,  dependent  upon  the  location  and  extent  of  the  lesion. 
If  the  pyramidal  tracts  are  involved  the  paralysis  is  soon  fol- 
lowed by  a  tendency  to  rigidity  and  cyanosis,  but  does  not 
cause  atroph3^  reaction  of  degeneration,  or  bed-sores.  Lesions 
in  the  anterior  horns  of  gray  matter,  on  the  other  hand,  pro- 


SYPHILIS    OF   THE    SPINAL   CORD  405 

duce  a  paralysis  which  is  often  confined  to  a  few  muscles, 
varies  in  intensity,  is  not  followed  by  rigidity,  and  does  result 
in  rapid  atroph}^  electrical  reaction  of  degeneration,  and  bed- 
sores. 

Both  the  pyramidal  tract  and  the  anterior  horns  may  be 
involved  simultaneously. 

Ataxia. — That  incoordination  or  disturbance  of  the  asso- 
ciated muscular  action  essential  to  the  maintenance  of  equi- 
librium which  we  term  ataxia  "  is  due  to  an  interference  with 
the  reception  of  sensations  of  muscular  sense  .  .  .  sent  in 
from  the  skin,  joints,  or  muscles.  These  sensations  may  be 
intercepted  as  they  pass  through  the  nerves,  for  ataxia  is  a 
symptom  of  multiple  neuritis;  they  may  be  intercepted  as  they 
pass  through  the  column  of  Burdach,  as  is  the  case  in  loco- 
motor ataxia ;  .  .  .  they  may  be  intercepted  in  the  cerebellum. 
.  .  .  Ataxia  from  neuritis  is  usually  accompanied  by  tender- 
ness in  the  nerves  and  muscles.  Ataxia  from  cerebellar  disease 
is  present  only  in  the  act  of  walking,  and  is  attended  by  ver- 
tigo "  (Starr). 

Ocular  Symptoms. — Reflex  iridoplegia  (Argyll-Robert- 
son pupil),  which  Babinsky  and  Charpentier  ^  consider  pathog- 
nomonic of  syphilis,  and  which  is  so  early  and  characteristic 
a  sign  of  tabes,  is  sometimes  found  with  syphilis  of  the 
cord,  though  a  total  paralysis  of  accommodation  to  distance 
as  well  as  to  light  is  much  more  typical  of  the  latter  con- 
dition. This  total  paralysis  of  the  iris  is  extremely  rare  in 
true  tabes. 

Paralysis  of  the  external  muscles  of  the  eye,  so  frequent 
during  the  course  of  tabes,  is  even  more  common  in  spinal 
syphilis. 

Trophic  Disturbances.  —  Excepting  the  relative  fre- 
quency of  dystrophic  joint  changes   (Charcot  joint)   in  tabes, 

'  La  syphilis,  1904,  vol.  ii,  p.  545. 


4o6  SYPHILIS   OP   THE   NERVOUS    SYSTEM 

the  trophic  disturbances  due  to  syphiHs  of  the  cord  are  in  no 
way  distinctive. 

Despite  its  great  irregularities,  syphiHs  of  the  cord  usu- 
ally conforms,  at  least  in  some  measure,  to  one  of  the  following 
types : 

Meningitis  and  meningo-myelitis. 

Paraplegia. 

Syphilitic  ataxia  with  exaggerated  reflexes. 

Meningitis  and  Meningo-myelitis. — The  meningitis  may 
be  localized,  diffused,  or  cerebro-spinal ;  it  may  be  accompanied 
or  succeeded  by  lesions  of  the  cord. 

Its  prime  symptoms  are  pain  (with  nocturnal  exacerba- 
tions) at  the  seat  of  the  lesion  and  rigidity  of  the  spine  (ex- 
cited by  the  pain),  especially  notable  if  the  lesion  is  seated  in 
the  neck. 

Secondary  symptoms  arise  from  compression  or  infiltra- 
tion of  the  nerves  and  cord. 

Severe  syphilitic  spinal  meningitis  is  extremely  rare.  The 
pain  is  so  marked  an  early  symptom  that  vigorous  early 
treatment  is  encouraged,  and  the  prognosis  is  therefore 
good. 

Paraplegia. — Transverse  myelitis,  whether  due  to  gumma, 
thrombosis,  or  embolism,  is  uncommon. 

The  usual  type  is  characterized  by  the  sudden  onset  (within 
a  few  hours)  of  paraplegia  accompanied  by  anesthesia.  The 
reflexes  are  exaggerated;  bladder  and  bowel  are  paralyzed. 
Within  a  few  weeks  contracture  of  the  paralyzed  muscles 
occurs ;  the  muscles  atrophy  and  bed-sores  appear  as  the  end 
approaches.  The  site  of  the  lesion  may  usually  be  determined 
by  an  area  of  hyperesthesia,  if  not  of  actual  pain,  and  also  by 
the  extent  of  the  paralysis  and  anesthesia. 

Some  improvement,  if  not  a  complete  cure,  may  be  looked 
for  if  the  case  is  vigorously  treated  before  the  muscles  become 
contractured.     After  this  little  can  be  done. 


SYPHILIS    OF    THE    SPINAL    CORD  407 

Brown-Sequard  Paralysis. — Hemiplegia  with  crossed 
hemianesthesia,  due  to  disease  of  one  half  of  the  cord,  is 
usually  caused  by  syphilis. 

Syphilitic  Ataxia  with  Exaggerated  Reflexes.  —  I  have  em- 
ployed the  above  stupid  title  because  the  disease  is  so  commonly 
mistaken  for  true  ataxia  with  abolished  reflexes.  The  two  con- 
ditions differ  in  many  of  their  clinical  details ;  but  recognition 
of  the  fact  that  true  tabes  never  produces  exaggerated  reflexes 
will  save  one  from  the  gross  error  of  confounding  them. 

PRODROMES.^The  onset  is  usually  extremely  insidious. 
The  first  symptom  may  be  sexual  impotence,  paralysis  of  the 
bladder  or  bowel,  or  irregularly  distributed  paresthesia.  This 
first  symptom  may  remain  unique  for  many  months,  and  by 
proper  treatment  the  disease  may  often  be  checked  before  it 
progresses  any  farther. 

Ataxia. — The  chief  subjective  symptom  is  a  slowly  pro- 
gressive ataxia.  This  ataxia  is  due  to  voluntary  spastic  con- 
tractions of  the  muscles.  The  patient  walks  stiff-legged,  with 
little  steps,  scarcely  lifting  his  feet  from  the  ground.  But  put 
his  muscles  at  rest  and  they  appear  entirely  normal,  neither 
spastic  nor  paralyzed;  their  electrical  reaction  is  unchanged. 

This  mincing  ataxia  is  utterly  different  from  the  incoordi- 
nate kicking  ataxia  of  tabes. 

Exaggeration  of  the  Reflexes.  —  The  knee-jerk  is 
greatly  exaggerated  and  ankle  clonus  is  marked.  Babinski  re- 
flex is  almost  always  present. 

Vesical  Paralyses. — The  vesical  and  rectal  paralyses, 
though  usually  present,  may  be  slight. 

Course. — The  progress  of  the  disease  is  generally  very 
slow.  It  often  requires  repeated  courses  of  treatment  to  effect 
a  cure — and  a  cure,  all  too  often,  means  nothing  more  than 
checking  the  progress  of  the  disease.  I  have  seen  a  sailor, 
after  many  months  of  spinal  syphilis,  return  to  the  shrouds, 
a  builder  to  his  ladder;  but  such  cases  are  exceptional.     The 


4o8  SYPHILIS   OF   THE   NERVOUS   SYSTEM 

best  we  can  do,  as  a  rule,  is  to  prevent  the  symptoms  from 
becoming  any  worse. 

PARASYPHILIDS 

An  adequate  brief  description  of  the  parasyphihds  is  im- 
possible here.  Rather  than  attempt  a  hasty  sketch  of  them, 
let  us  merely  refer  to  the  few  remarks  in  Chapter  VII. 

SYPHILIS    OF    THE    NERVES 

Syphilis  of  the  nerves  is  usually  secondary;  an  involvement 
from  disease  of  the  brain,  cord,  or  meninges  at  their  origin, 
or  from  the  bones  or  soft  tissue  that  surround  them  in  their 
course. 

Primary  ^.  syphilitic  neuritis  is  quite  rare.  One  or  more 
nerves  may  be  involved.  Its  symptoms  suggest  deficient  nerve 
conduction :  thus  there  is  paralysis,  anesthesia,  loss  of  reflexes, 
but,  above  all  things,  pain.  Neuritis  and  neuralgia  are  almost 
synonymous. 

The  diagnosis  is  often  obscure.  The  only  distinction  be- 
tween syphilitic  neuritis  and  that  due  to  another  cause  is  the 
nocturnal  exacerbation  characteristic  of  the  syphilitic  pain. 

The  treatment  is  especially  by  iodids. 

DIAGNOSIS 

Nerves. — The  diagnosis  of  syphilis  of  the  nerves  depends, 
as  we  have  seen,  upon  the  character  of  the  pain,  the  history, 
and  the  effect  of  treatment.  But  one  caution  must  be  added : 
however  positive  one  may  be  that  the  inflammation  is  syphilitic, 
one  can  rarely  be  absolutely  certain  that  it  is  in  the  nerves 


ij.  e.,  beginning  in  the  nerve;  not  a  secondary  extension  from  some  other 
tissue. 


DIAGNOSIS  409 

alone  and  not  in  the  central  nervous  system  as  well.  Hence 
one  must  always  be  on  the  lookout  for  symptoms  of  central 
involvement. 

Brain  and  Cord. — The  features  differentiating  syphilis 
from  other  diseases  of  the  central  nervous  system  are : 

1.  Prodromes. 

2.  Irregular  course. 

3.  Irregular  involvement. 

4.  Age  of  the  patient. 

5.  Occurrence  of  certain  lesions. 

6.  History  and  evidences  of  previous  syphilis. 

7.  Examination  of  the  cerebro-spinal  fluid. 

8.  Amenability  to  treatment. 

Prodromes. — These   have   already   been   discussed    (page 

378). 

Irregular  Course. — The  three  case-histories  cited  are 
absolutely  typical  of  syphilis  in  their  confusing  advance  and 
retreat  from  one  to  another  symptom  of  nervous  disorder. 

Irregular  Involvement. — Equally  characteristic  is  the 
multiplicity  of  heterogeneous  symptoms;  e.g.,  the  juxtaposi- 
tion of  epilepsy  with  facial  paralysis,  of  hemiplegia  with  de- 
mentia— and  the  incompleteness  of  these  symptoms;  e.  g.,  par- 
tial paralyses,  irregular  areas  of  anesthesia,  temporary  or 
incomplete  loss  of  the  mental  functions. 

Age  of  th.e  Patient. — As  we  have  seen,  the  later  the 
syphilis  is  acquired,  the  earlier  do  its  nervous  symptoms  ap- 
pear. Hence,  syphilis  of  the  nervous  system  begins  almost 
always  between  the  ages  of  twenty-two  and  forty-four,^  at 
the  very  time  of  life  when  other  lesions  of  the  nervous  system 
are  most  uncommon. 

Now   this   fact   is  of  especial   import   in   diagnosing  two 

1  Out  of  368  cases,  2  began  at  nineteen,  i  at  twenty-two,  311  (85  per  cent) 
between  twenty-two  and  forty-four,  28  between  forty-five  and  fifty,  24  between 
fifty-one  and  fifty-nine,  i  at  sixty -one,  and  i  at  sixty-three. 


4IO  SYPHILIS    OF    THE    NERVOUS    SYSTEM 

lesions:  viz.,  epilepsy  and  hemiplegia.  Epilepsy  beginning 
after  the  thirtieth  year  is  almost  always  syphilitic,  for  "  idio- 
pathic "  epilepsy  is  a  disease  of  early  youth.  Moreover,  hemi- 
plegia occurring  before  the  forty-fifth  year  is  almost  always 
syphilitic,  for  hemorrhage,  thrombosis,  or  embolism  due  to 
other  causes  is  extremely  rare  until  the  patient  is  more  than 
forty-five  years  old. 

Typical  Syphilitic  Conditions. — Certain  symptoms  are 
very  suggestive  of  brain  syphilis :  such  are  Jacksonian  epi- 
lepsy, paralysis  of  the  third  and  to  a  less  degree  of  the  second 
cranial  nerves,  and,  as  we  have  just  seen,  hemiplegia  before 
the  age  of  forty-five,  or  epilepsy  beginning  after  the  age  of 
twenty  years.  All  partial  paralyses,  hemiplegias  without  loss 
of  consciousness,  as  well  as  all  complicated,  irregular,  and 
abortive  symptoms  are  also  gravely  suspect. 

History. — Excepting  tabes  and  paresis,  syphilis  of  the 
nervous  system  almost  always  gives  evidence  of  previous  syphi- 
litic lesions. 

Examination  of  Cerebro-spinal  Fluid. — The  charac- 
teristic lymphocytosis  caused  by  syphilis  is  usually  (though  not 
always)  present,  and  may  confirm  the  diagnosis  of  a  doubtful 
case. 

Treatment. — The  test  of  treatment  is  always  the  court 
of  last  resort.  Let  us  once  again  insist  that  apparent  improve- 
ment under  treatment  is  not  absolute  proof  that  the  lesion  is 
syphilitic  nor  is  resistance  to  treatment  absolute  proof  that  it 
is  not. 


CHAPTER    XXVII 
SYPHILIS  OF   THE  EYE^ 

Syphilis  strikes  the  eye  so  frequently  in  certain  regions, 
so  rarely  in  others,  that  it  is  more  convenient  to  consider  its 
lesions  in  order  of  their  frequency  rather  than  in  any  cut-and- 
dried  anatomical  precedence. 

Accordingly,  we  may  take  up  in  turn  iritis,  chorio-retinitis, 
and  optic  neuritis,  closing  with  a  brief  survey  of  the  rarer 
manifestations  of  acquired  ocular  syphilis. 

IRITIS 

Inflammation  of  the  iris  occurs  in  at  least  half  of  all  cases 
of  ocular  syphilis.  It  is  said  to  be  more  frequent  in  men  than 
in  women.  It  afTects  some  three  to  four  per  cent  of  all  syphi- 
litics  (Terrien-).  It  occurs  usually  between  the  fourth  and 
the  twelfth  month  of  the  disease.  Half  the  cases  of  iritis  seen 
by  the  ophthalmologist  are  said  to  be  syphilitic. 

Etiology. — While  the  connection  between  eye-strain  and 
syphilitic  iritis  is  by  no  means  established  and  grosser  trauma 
can  hardly  be  invoked  as  a  cause,  it  is  nevertheless  evident  that 
a  severe  case  of  syphilitic  iritis  predisposes  the  patient  to  re- 
lapse. But  this  predisposition  is  due  rather  to  the  permanence 
of  adhesions  than  to  inefficient  treatment  of  the  first  attack. 

Double  iritis,  the  inflammation  in  one  eye  following  close 
upon  that  in  its  fellow,  is  very  common. 


» Reviewed  by  Dr.  John  Izard  Middleton. 
2 "  Syphilis  de  I'oeil,"  Paris,  1905. 

■    411 


412 


SYPHILIS    OF   THE    EYE 


Pathology.  — The  inflammation  is  usually  exudative  in  type 

(plastic  iritis).  There  is  exudation  within  the  iris,  thickening 
it  and  dulling  its  luster ;  the  iris  is  contracted  and  almost  immo- 
bile. The  congestion  always  extends  to  the  ciliary  body,  though 
there  is  rarely  any  symptom  of  its  involvement.  The  vessels 
about  the  cornea  are  dilated  and  form  the  characteristic  cir- 
cumcorneal  congestion. 

If  the  inflammation  is  severe  desquamation  into  the  ante- 
rior chamber  produces  a  sediment  behind  the  cornea  which 
occasions  a  spotted  appearance  upon  its  lower  segment,  and  is 
therefore  inaccurately  entitled  "  punctate  keratitis." 

A  neglected  case  results  in  adhesions  between  the  iris  and 
the  lens,  which,  if  marked,  may  destroy  vision. 

Exceptionally,  there  occurs  what  is  known  as  the  papil- 
lomatous or  condylomatous  ^  iritis,  characterized  by  the  erup- 
tion of  a  papule  (rarely  more  than  one),  the  size  of  the  head 
of  a  pin,  projecting  from  the  pupillary  border  of  the  iris  or 
from  its  anterior  surface.  True  gumma  of  the  iris  is  ex- 
tremely rare. 

Symptoms. — The  subjective  symptoms  are  hazy  vision 
and  pain,  which,  if  severe,  excites  photophobia  and  a  constant 
lacrymation.  These  symptoms  vary  in  intensity,  but  are  usu- 
ally slight.  The  pain  is  situated  in  the  eye,  brow,  or  temple 
indifferently. 

The  objective  symptoms  upon  which  a  diagnosis  of  iritis 
is  based  are  found  in  the  iris,  the  pupil,  the  cornea,  and  the 
sclera. 

The  iris  is  dull  in  color,  looks  thick,  and  often  is  more 
greenish  or  rusty  than  its  fellow.  It  is  fixed  in  contraction 
(does  not  expand  in  darkness),  and  reacts  much  more  slowly 
to  mydriatics  than  its  fellow.  If  adhesions  (synechiae)  have 
already  formed  between  it  and  the  lens,  instillation  of  atropin 

1  Erroneously  termed  gummatous,  for  these  little  tumors  scarcely  ever 
degenerate.     But  they  are  yellomsh  and  therefore  look  like  gumma, 


IRITIS  413 

either  does  not  dilate  the  pupil  at  all  or,  more  often,  does  dilate 
it  somewhat,  but  in  a  characteristically  irregular  manner.  The 
adhesions  binding  portions  of  the  iris  impart  to  the  dilated 
pupil  all  sorts  of  fantastic  shapes  (clover  shape,  heart  shape, 
etc.). 

An  exceptionally  mild  inflammation  shows  only  a  slight 
discoloration  or  thickening,  which  may  be  confined  to  the 
pupillary  border. 

A  grave  lesion,  on  the  other  hand,  apart  from  the  marked 
discoloration  and  thickening  of  the  iris  with  salient  blood-ves- 
sels and  its  prompt  and  firm  adhesion  to  the  lens,  may  produce 
the  yellowish  pinhead  papules  projecting  from  the  pupillary 
border  or  the  broader  yellowish  papules  on  its  anterior  surface. 

The  pupil  is,  as  already  stated,  small,  fixed,  and,  if  dilated, 
often  irregular.  It  is  also  blurred  in  severe  cases  by  the  iritic 
exudate. 

The  cornea  may  be  seemingly  spotted  (the  so-called  punc- 
tate keratitis)  or  blurred  by  exudate  into  the  anterior  cham- 
ber.^    There  may,  moreover,  be  actual  keratitis. 

The  sclera  reveals  to  the  examining  eye  and  finger  two  most 
important  objective  symptoms  of  iritis — circumcorneal  injec- 
tion and  the  presence  or  absence  of  tenderness. 

Circumcorneal  injection  consists  in  dilatation  of  the  ante- 
rior ciliary  vessels  surrounding  the  cornea.  The  cornea  is  sur- 
rounded by  a  bright-red  circle  of  congestion,  which  gradually 
thins  out  toward  its  periphery  into  a  series  of  dilated  little 
vessels,  extending  for  some  distance  radially  over  the  scle- 
rotic. This  sign  is  constant  and  characteristic  of  iritis.  In 
order  to  distinguish  this  congestion  from  true  conjunctivitis 
one  has  but  to  touch  the  conjunctiva  lightly,  moving  it  from 
side  to  side  upon  the  eyeball,  whereupon  the  immobility  of  the 
vessels  shows  that  they  are  beneath  and  not  in  the  conjunctiva. 

*  Gelatiniform  exudate  is  rare:  purulent  or  bloody  exudate  most  exceptional. 


414  SYPHILIS    OF    THE    EYE 

By  pressure  upon  the  sclera  through  the  upper  Hd  we  dis- 
cover the  tenderness  and  tension  of  the  eye  as  compared  with 
its  fellow.  In  the  ordinary  mild  case  of  iritis  ocular  tension 
is  slightly  diminished,  and  there  is  little  or  no  circumcorneal 
tenderness.  The  presence  of  extreme  sensitiveness  to  pressure 
shows  cyclitis  and  suggests  the  possibility  of  grave  involve- 
ment of  the  choroid  or  retina,  while  increased  tension  is  an 
even  more  ominous  sign,  since  it  is  a  threat  of  glaucoma. 

Complications. — Let  us  not  forget  that  iritis  may  be  the 
most  obvious  though  the  least  ominous  lesion  of  syphilis  of 
the  eyeball.  It  is  not  proper  to  speak  of  such  important  lesions 
as  chorio-retinitis,  optic  neuritis,  keratitis,  gumma  of  the  cil- 
iary body,  etc.,  as  complications  of  iritis.  It  is  the  iritis  rather 
that  complicates  them. 

The  most  important  complication  resulting  from  iritis  is 
the  persistence  of  adhesions  with  the  implied  impairment  of 
vision  and  danger  of  relapse  and  of  ultimate  glaucoma. 

Diagnosis. — The  physician  must  learn  whether  there  is 
iritis,  whether  the  iritis  is  syphilitic,  and  whether  the  syphilitic 
iritis  stands  alone  or  is  but  a  complication  of  other  and  graver 
lesions. 

The  diagnosis  of  iritis  need  not  be  discussed  here.  Suffice 
it  to  remark  with  Theobald  that  "  speaking  generally,  the  pres- 
ence of  iritis  is  to  be  suspected  whenever,  without  increase  of 
intra-ocular  tension  or  other  evident  cause,  pain  in  and  around 
the  eye,  usually  worse  at  night,  is  complained  of  and  is  accom- 
panied by  circumcorneal  injection  and  a  contracted  pupil." 
Such  a  suspicion  is  confirmed  by  the  discovery  that  the  iris 
is  thick,  discolored,  contracted,  and  sluggish.  The  presence 
of  adhesions  and  of  punctate  keratitis  drive  the  conclusion 
home. 

But  in  all  this  there  is  nothing  to  show  that  the  iritis  is 
syphilitic.  Indeed,  except  for  the  yellow  papules  (that  occur 
so  rarely)  there  is  no  sign  to  distinguish  syphilitic  iritis  from 


IRITIS  415 

that  due  to  whatever  cause.  Yet  the  diagnosis  is  almost  in- 
variably established  by  the  presence  of  other  syphilitic  lesions 
and  a  history  of  recent  "  early  syphilis."  The  iritis  standing 
alone  is  very  likely  to  be  dubbed  rheumatic.^ 

Is  the  iritis  but  one  of  a  number  of  ocular  lesions?  This 
question  always  merits  an  accurate  answer ;  for,  while  no  lesion 
is  more  benign  than  the  mild  iritis  of  early  syphilis,  no  lesion 
is  more  fatally  misleading  than  that  same  iritis  when  it  con- 
ceals the  onset  of  chorio-retinitis. 

Hence  every  syphilitic  iritis  demands  a  thorough  ophthal- 
moscopic examination  at  the  outset. 

Prognosis.  — The  prognosis  of  uncomplicated .  syphilitic 
iritis  is  absolutely  good.  Dilate  the  pupil  to  prevent  adhesions, 
and  the  iritis  will  soon  disappear  spontaneously  in  most 
instances. 

This  tendency  to  spontaneous  resolution  has  persuaded 
many  ophthalmologists  to  neglect  the  specifics  in  the  treatment 
of  iritis.-  But  their  arguments  apply  equally  to  the  early  sec- 
ondary syphilids  which  iritis  accompanies.  Moreover,  one  can 
never  be  absolutely  sure  that  an  apparently  benign  iritis  is  not 
a  warning  of  graver  lesions  to  come. 

Treatment. — The  iris  must  be  immediately  dilated  by  the 
instillation  of  two  drops  of  a  three  per  cent  solution  of  atropin 
sulphate  twice  a  day  (or  oftener  if  this  does  not  sufifice)  until 
full  dilatation  is  attained,  and  then  kept  dilated  by  a  one  per 

'  Fournier  lays  great  stress  upon  the  insidious  onset  and  benign  character 
of  syphilitic  iritis  as  a  diagnostic  feature.  "The  less  the  iritis  disturbs  the 
patient  the  more  it  should  disturb  the  physician,"  is  his  rule. 

2  Thus  Noyes  (" Genito-Urinary  Diseases  with  Syphilis,"  Keyes,  1888,  p, 
621)  says:  "I  have  no  hesitation  in  stating  that  the  usefulness  of  either  mercury 
or  iodin  to  cure  iritis  is  exceptional  and  not  the  rule.  ...  I  have  several  times 
observed  patients  with  active  iritis  in  one  eye,  who  have  already  been  brought 
under  the  influence  of  mercury,  attacked  with  the  same  inflammation  in  the 
other.  This  certainly  proves  that  no  preventive  virtue  can  be  ascribed  to  the 
mercury,  and  argues  against  the  beneficial  influence  of  quick  mercurialization 
in  curing  the  acute  attack." 


4l6  SYPHILIS    OF   THE    EYE 

cent  solution  until  the  inflammation  subsides.  In  case  the 
dilatation  is  not  begun  until  light  adhesions  have,  formed,  these 
will  gradually  break  up ;  but  if  they  do  not  yield,  and  are  dense 
and  broad,  they  require  iridectomy  after  the  subsidence  of 
the  attack. 

The  eye  must  be  protected  from  the  light  by  smoked 
glasses. 

Local  applications,  such  as  leeches,  boric  acid  or  lead  and 
opium  compresses,  may  be  employed  secundum  artem. 

If  there  is  liypertension  atropin  should  not  be  used,  and  an 
operation  will  probably  be  required  to  relieve  the  increased 
tension. 

General  treatment  is  mercurial;  mild  if  the  iritis  is  slight, 
pushed  severely  if  it  is  grave,  accompanied  by  iodid  if  other 
lesions  require  it. 

CHORIORETINITIS    AND    RETINITIS 

Syphilis  is  the  most  frequent  cause  of  chorio-retinitis,^ 
one  of  the  rare  causes  of  retinitis.  Yet,  though  syphilitic 
chorio-retinitis  is  far  less  rare  than  syphilitic  retinitis,  it  is 
not,  for  all  that,  a  frequent  lesion.  It  is  said  by  some  authors 
to  be  most  often  due  to  hereditary  syphilis,  while  others  attrib- 
ute it  usually  to  the  acquired  form  of  the  disease.  It  may  be 
accompanied  by  iritis.     It  is  usually  unilateral. 

Pathology. — The  vessels  of  the  choroid  are  congested  and 
infiltrated,  there  are  foci  of  yellow  or  white  exudate  upon  its 
surface,  which  are  later  surrounded  by  pigment  deposit,  and  a 
fibrous  exudate  into  the  vitreous. 

The  changes  in  the  retina  are  a  hyperemia  and  edema. 
The  ophthalmoscope  shows  haziness  and  discoloration  of  the 
retina ;  the  arteries  appear  thickened  and  surrounded  by  a  whit- 

»  The  choroid  can  scarcely  be  said  to  be  inflamed  without  some  affection  of 
the  superposed  retina. 


CHORIO-RETINITIS    AND    RETINITIS  417 

ish  exudate  at  first,  while  late  in  the  disease  they  are  obliter- 
ated and  reduced  to  fibrous  threads. 

Hemorrhages,  sclerotic  patches,  pigmentary  (unilateral) 
retinitis,  detachment  of  the  retina,  De  Graefe's  relapsing  cen- 
•tral  retinitis,  etc..  are  among  the  rare  results  of  ocular  syphilis. 

Symptoms. —  Diinncss  of  vision  is  the  cardinal  subjective 
symptom  of  chorio-retinitis  and  retinitis.  Since  this  dimness 
of  vision  progresses  very  slowly  and  painlessly,  and  is  always 
unilateral  at  first,  the  patient  usually  does  not  seek  relief  until 
it  has  existed  for  some  time  and  wrought  organic  and  uncur- 
able  lesions  in  the  retina.  Therefore,  the  prognosis  is  gener- 
ally bad. 

Analysis  of  this  dimness  of  vision  shows  it  to  be  a  hazi- 
ness, a  fog,  a  dense,  constantly  moving  cobweb,  through  which 
objects  are  more  or  less  obscurely  seen.  Moreover,  objects 
are  likely  to  appear  diminished  in  size  (rarely  deformed), 
and  certain  colors  are  distinguished  only  partially  or  not  at 
all.  Vision  is  markedly  impaired  when  the  light  is  at  all 
dim,  and  the  patient's  outlook  upon  the  world  may  be  still 
further  confused  by  the  presence  of  dancing  flames  and  flecks 
of  light   (photopsia). 

Pain  is  absent  or  slight. 

The  ophthalmoscope  shows  a  haziness  in  the  vitreous,  ob- 
scuring the  papilla,^  but  clearing  toward  the  periphery.  This 
haziness  is  constituted  by  flakes  of  fibrin,  varying  widely  in 
size  in  different  cases,  or  in  the  same  case  from  time  to  time. 
Indeed,  great  variations  occur  in  the  density  of  this  haze  that 
obscures  the  sight,  lout  these  remissions  do  not  necessarily 
imply  a  good  prognosis. 

Implication  of  the  choroid  is  evinced  by  the  exudative  foci. 
These  foci  at  first  form  yellowish  projections  surrounded  by 
a  pigmented  circle;  they  lift  up  the  retina.     They  last  a  few 

'The  papilla  looks  like  "a  moon  seen  through  clouds." 


4i8  SYPHILIS    OF    THE    EYE 

weeks,  and  then  disappear,  leaving  pitted,  bluish-white  scars 
amidst  irregular  masses  of  pigment.  The  scars  represent  com- 
plete destruction  of  the  retina  and  choroid  by  the  exudate;  so 
that  when  it  withers  the  white  sclera  appears,  more  or  less 
obscured  by  little  agglomerations  of  pigment. 

Meanwhile  the  papilla  is  slowly  fading.  It  becomes  a 
dirty  yellow,  then  gray,  and  finally  is  completely  atrophied. 
This  process  usually  takes  many  months,  and  by  the  time  it 
is  well  advanced  the  other  eye  is  also  involved. 

Varieties. — In  order  of  frequency  the  chief  varieties  are: 

Disseminate  Chorio-retinitis.  —  The  inflammation  is 
general,  the  papules  are  numerous  around  the  periphery  of  the 
fundus,  rarer  toward  the  center. 

Anterior  Chorio-retinitis. — Especially  common  in  he- 
reditary syphilis  accompanying  interstitial  keratitis  (page 
531).  The  papules  affect  only  the  extreme  periphery,  and 
require  a  very  careful  examination  to  discern  them.  If  the 
papules  do  not  invade  the  fundus,  the  prognosis,  as  regards 
vision,  is  good. 

Irido-choroiditis. — Attacks  of  iritis  in  the  course  of  a 
choroiditis  are  not  uncommon,  and  are  an  evil  omen  unless 
the  choroiditis  is  extremely  slight  (anterior  chorio-retinitis, 
areolar  chorio-retinitis). 

Areolar  Chorio-retinitis. — The  papules  are  few  and 
irregularly  distributed.  This,  like  the  anterior  chorio-retinitis, 
is  a  partial  and  benign  type  of  "  disseminate  "  lesion. 

Central  Chorio-retinitis. — The  choroid  lesions  are 
centered  at  the  papilla  and  macula;  sight  is  rapidly  im- 
paired. 

Retinitis. — The  lesions  are  those  of  chorio-retinitis  less 
the  exudate.  Special  varieties,  such  as  relapsing  central  reti- 
nitis (De  Graefe),  retinitis  with  annual  scotoma  (Perlia, 
Bull),  etc.,  are  chiefly  of  interest  to  the  specialist.  Pigmentary 
retinitis  is  often  due  to  hereditary  syphilis. 


OPTIC    NEURITIS 


419 


Prognosis. — The  prognosis  is  bad.  The  lesions  are  usu- 
ally so  far  advanced  before  treatment  is  instituted  that  check- 
ing the  disease  only  partially  restores  sight. 

Neglected  cases  not  only  lose  the  sight  of  both  eyes,  but 
may  go  on  to  cataract  or  to  glaucoma,  requiring  enucleation. 

Treatment. — These  graver  lesions  of  ocular  syphilis  re- 
quire sharp  mercurialization,  preferably  by  intramuscular  in- 
jection combined  with  repeated  short,  sharp  courses  of  iodids. 

For  local  treatment  little  can  be  done.^  Terrien  speaks  well 
of  pilocarpin  hypodermically. 

OPTIC    NEURITIS 

The  optic  nerve  is  said  to  contribute  twenty-five  per  cent 
of  ocular  syphilis.  It  is  one  of  the  common  nerve  lesions  (cf. 
page  372). 

The  symptoms  of  optic  neuritis :  viz.,  amblyopia,  blind- 
ness, flittering  scotoma,  and  hemianopsia,  may  or  may  not  be 
due  to  lesions  visible  through  the  ophthalmoscope.  Accord- 
ingly, some  cases  (and  they  are  the  milder  ones)  are  distin- 
guished only  by  subjective  symptoms,  while  others  (and  they 
are  the  majority)  show  visible  lesions  of  the  papilla. 

On  the  other  hand,  one  may  occasionally  discover  a  choked 
disk  in  a  patient  who  shows  no  ocular  symptoms. 

Pathology. — Lesions  of  the  optic  nerve  may  be  primary  or 
secondary;  i.  e.,  due  to  syphilis  of  the  nerve  itself  or  to  lesions 
of  the  surrounding  parts.  It  is  thus  often  associated  with  other 
evidences  of  basilar  meningitis,  or  gumma  of  the  base  of  the 
brain,  or  of  the  sphenoidal  fissure,  or  within  the  orbit.  The 
commonest  syphilitic  cause  of  optic  neuritis  is  basilar  menin- 

1  Subconjunctival  injections  of  normal  salt  solution,  gelatin  (five  per  cent), 
cyanid  of  mercury  (i:  1,000),  and  iodo-iodid  solution)  iodin  0.02;  potass,  iodid. 
2.;  aq.  ad  40)  are  commended  for  various  ocular  lesions.  But  the  best  authori- 
ties do  not  favor  such  treatment.     Cf.  Bull,  J.Am.  Med.  Ass'n.,  1906,  vol.  xlvii, 

P-  823. 

29 


420 


SYPHILIS    OF    THE    EYE 


gitis.  Although  primary  (intraocular)  lesions  of  the  nerve 
are  habitually  associated  with  chorio-retinitis,  and  secondary 
lesions  with  other  evidences  of  syphilis  of  the  nervous  system, 
it  is  not  always  possible  to  ascertain  precisely  the  site  of  the 
lesion;  nor  is  it  always  a  simple  matter  to  decide  whether  a 
secondary  optic  neuritis  is  due  to  syphilis  or  to  brain  tumor. ^ 
Apart  from  the  diagnostic  signs  alluded  to  in  the  preceding 
chapter  (page  408)  one  must  often  apply  the  therapeutic 
test. 

The  lesions  visible  by  ophthalmoscope  are  neuro-retinitis, 
papillitis,  and  optic  atrophy.  There  is  nothing  distinctively 
syphilitic  about  any  of  them.  They  may,  therefore,  be  dis- 
missed with  brief  mention. 

Neuro-retinitis. — Already  alluded  to ;  varies  from  sim- 
ple hyperemia  to  marked  congestion,  edema,  and  blurring  of 
outline. 

Papillitis. — Papillitis,  or  choked  disk,  is  a  condition  of 
marked  edema.  The  nerve  is  much  swollen  and  projects  for- 
ward from  the  surrounding  retina.  It  is  opaque,  red,  and 
striated,  its  arteries  small,  its  veins  much  congested,  its  edge 
indistinct. 

The  cause  of  choked  disk  is  interrupted  venous  return, 
due  in  part  to  pressure  upon,  in  part  to  inflammation  of  the 
nerve.     Its  outcome,  if  neglected,  is  optic  atrophy. 

Optic  Atrophy. — The  optic  nerve  may  atrophy  "  pri- 
marily "  or  subsequently  to  chorio-retinitis  or  papillitis. 

When  the  atrophy  is  "  primary "  the  papilla  gradually 
loses  its  rosy  color  and  becomes  white  or  gray  - ;  its  outline 
is  clean-cut,  and  the  retinal  vessels  are  not  markedly  changed. 

Optic  atrophy  following  papillitis,   on  the  contrary,  pro- 

1  Bilateral  optic  neuritis  is  almost  an  infallible  sign  of  basilar  tumor  or 
meningitis. 

2  Gray  atrophy  is  usually  due  to  tabes,  white  atrophy  to  cerebral  cause;  but 
this  rule  is  not  without  exceptions. 


GUMMA   OF   THE    UVEAL   TRACT  421 

duces  a  white  or  gray  papilla  with  irregular  vague  outline, 
and  with  tortuous  retinal  veins  and  slender  sclerotic  arteries. 

Optic  atrophy  following  chorio-retinitis  shows  the  scars 
of  the  choroidal  exudate  scattered  over  the  fundus. 

Symptoms. — There  may  be  symptoms  without  ophthalmo- 
scopic signs  of  optic  neuritis,  less  often  signs  without  symp- 
toms, most  often  both  together.  The  symptoms  are  similar 
to  those  of  chorio-retinitis,  and  consist  chiefly  of  a  gradual 
loss  of  vision.  Sudden  and  temporary  improvement  or  diminu- 
tion of  vision  is  characteristic  of  disease  of  the  optic  nerve 
rather  than  of  the  retina. 

The  disease  may  be  checked  by  mixed  treatment.  But  if 
actual  atrophy  has  occurred  no  treatment  will  restore  sight. 

Diagnosis. — The  diagnosis  is  made  by  the  ophthalmoscope, 
with  the  reserve  that  the  lesions  are  not  always  visible  at  the 
onset. 

Treatment. — As  for  the  cerebral  lesions,  with  which  it  is 
usually  connected. 

GUMMA  OF  THE  UVEAL  TRACT 

Iris. — Gumma  of  the  iris  has  been  mentioned;  it  is  ex- 
tremely rare. 

Ciliary  Body. — Panas  ^  has  collected  thirty  cases.  The 
gumma  appears  as  a  complication  of  iritis.  The  tumor  in- 
volves and  pierces  the  sclerotic,  appearing  as  a  little  granulat- 
ing mass;  it  also  invades  the  iris.  It  may  be  distinguished 
from  tuberculosis  by  the  history  and  associated  lesions.  Instil- 
lations of  atropin  and  sharp  mixed  treatment  are  demanded. 

Choroid. — Terrien  has  collected  six  cases,  and  says:  "  The 
ophthalmoscope  reveals  a  white  neoplasm  in  the  fundus.  The 
gumma  is  soon  complicated  by  iritis,  optic  neuritis,  and  even 
by  rupture  of  the  sclera  at  the  point  affected.     It  may  be  mis- 

1  Arch,  d'  Ophthal.,  1902,  August,  p.  485. 


422  SYPHILIS    OF    THE    EYE 

taken  for  sarcoma,  but  the  progress  of  the  disease  and  effi- 
ciency of  (mixed)  treatment  should  prevent  this  error," 


CONJUNCTIVAL    SYPHILIS  i 

Slight  congestion  of  the  conjunctiva  may  accompany  the 
first  general  secondary  outbreak;  severe  congestion,  simulating 
trachoma,  is  extremely  rare. 

Papular  conjiinctiz'itis  is  a  rare  complication  of  iritis  (or 
of  a  papular  eruption  upon  the  skin  of  the  eyelids).  The 
papules  may  be  movable  or  attached   (episcleritis). 

Mucous  papules  and  ulcers  are  sometimes  seen  upon  the 
edge  of  the  eyelid. 

Conjunctii'al  guniinata  have  been  noted.  They  are  usually 
single  and  situated  at  some  distance  from  the  cornea :  they  arise 
from  the  subconjunctival  tissue. 

KERATITIS    AND    SCLERITIS 

Interstitial  keratitis  is  so  uncommon  in  acquired  syphilis, ^ 
and  so  characteristic  of  inherited  syphilis  that  we  may  defer 
its  description  (page  531). 

Episcleritis  without  conjunctivitis  is  extremely  rare.  One 
or  more  small  tubercles  appear  near  the  cornea  and  adherent 
to  the  sclera.  It  is  usually  a  complication  of  iritis.  It  is  dif- 
ferentiated from  rheumatic  episcleritis  by  the  absence  of  sen- 
sitiveness (Terrien). 

Scleritis  is  constituted  by  one  or  more  similar  tubercles 
embedded  in  the  sclera.  Panas  has  suggested  that  these  are 
actually  an  extension  of  a  gumma  of  the  ciliary  body. 

Gumma  of  cornea  and  sclerotic  are  alleged,  but  not  proven 
to  exist. 

'  Cf.  Pusey,  J.  Am.  Med.  Ass'n.,  1907,  vol.  xlix,  p.  S28. 
2  ;My  records  contain  only  two  cases. 


ORBITAL    LESIONS  423 

SYPHILITIC    TARSITIS 

Occurs  in  the  latter  stages  of  syphilis,  and  is  to  be  regarded 
as  a  gummatous  infiltration  of  the  tarsus.  Develops  grad- 
ually, and  without  noticeable  pain.  At  its  height  there  is 
great  enlargement  of  the  lids,  and  their  skin  is  reddened  and 
stretched.  The  tarsus  itself  feels  hard,  and  does  not  allow 
eversion  of  the  lid,  for  examination;  also  appears  pale  and 
lardaceous.  The  lashes  fall  out.  The  preauricular  glands 
swell.  The  course  is  tedious,  affection  lasting  some  weeks, 
but  yielding  to  specifics. 

THE    LACRYMAL    APPARATUS 

The  Lacrymal  Gland. — Syphilitic  dacryoadenitis  is  ex- 
tremely rare.  It  is  characterized  by  a  painless  infiltration  of 
the  gland,  forming  a  little  tumor  in  the  upper  and  outer  por- 
tion of  the  lid.     It  is  usually  mistaken  for  tuberculosis. 

The  Tear  Duct. — Syphilis  of  the  lacrymo-nasal  duct  oc- 
curs only  in  connection  w^ith  extensive  ulcerations  of  the  nose 
or  destruction  of  the  nasal  bones.  The  resulting  stricture  (after 
the  inflammation  has  been  controlled)   requires  dilatation. 

ORBITAL    LESIONS 

Osteoperiostitis  and  gumma  of  the  orbital  bones  are  im- 
portant chiefly  on  account  of  their  effect  upon  the  eye. 

Inflammation  in  the  edge  of  the  orbit  excites  the  usual 
symptoms  of  bone  syphilis,  i.  e.,  localized  pain  and  swelling, 
and  involves  the  lower  lid  in  the  inflammation.  Deeper  in 
the  orbit  it  may  cause  exophthalmos,  optic  neuritis,  diplopia 
(by  muscle  or  nerve  involvement),  and  even  neuro-paralytic 
keratitis,  etc.  It  may  terminate  in  resorption,  gummy  degen- 
eration, or  suppuration. 


CHAPTER    XXVIII 

SYPHILIS  OF  BONE 

Bone  syphilis  and  brain  syphilis  resemble  each  other  in 
this  important  particular;  either  may  manifest  itself  first  by 
pain  (osteocopic  pains,  headache)  at  the  time  of  the  first  gen- 
eral outbreak  of  symptoms,  and  later  the  disease  may  follow 
one  of  three  courses,  viz. : 

1.  The  pain  having  been  relieved  by  time  or  treatment  no 
further  bone  (or  brain)  lesions  may  appear,  or 

2.  The  pain  may  be  followed  (with  or  without  an  interval 
of  remission)  by  grave  bone  (or  brain)  lesions,  or 

3.  The  grave  lesions  may  attack  a  bone  (or  brain)  in 
which  no  pain  was  felt  at  the  onset  of  secondary  symptoms. 

Thus  the  early  osteocopic  pains,  which  have  been  already 
described  (page  263)  need  concern  us  here  only  inasmuch  as 
they  may  precede  a  graver  lesion. 

The  bone  may  be  secondarily  involved  by  syphilis  of  the 
surrounding  tissues,  or  the  inflammation  be  primary  in  the 
bone  itself  or  in  its  periosteum.  Of  the  secondary  lesions,  the 
only  important  ones  are  the  bone  lesions  of  nose  and  palate 
already  described  (page  363).  The  chief  primary  lesions  are 
indicated  in  the  table  on  the  opposite  page. 

In  this  table  all  lesions,  whether  unilateral  or  bilateral, 
periosteal  or  medullary,  productive  or  gummatous,  are  grouped 
together. 

Bilateral  Lesions. — Though  .bilateral,  symmetrical,  peri- 
osteal tenderness  is  preeminently  an  early  symptom;  bilateral 
424 


SYPHILIS    OF    BONE 


425 


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graver  lesions  are  distributed  relatively  late.  Of  37  recorded 
bilateral  lesions  (31  tibial),  11  are  of  unknown  date,  9  oc- 
curred in  the  first  three  years,  8  in  the  next  three,  3  in  the 
ninth,  and  i  in  the  tenth,  twelfth,  thirteenth,  fifteenth,  and 
twenty-first  years. 

Multiple  Lesions. — Though  diffuse  lesions  are  not  uncom- 
mon, multiple,  discrete  lesions  of  one  bone  are  rare.^  But  the 
290  -  lesions  in  the  table  occurred  in  224  cases,  there  being 
63  in  which  two  or  more  bones  were  involved  (exclusive  of 
the  2i7  bilateral,  symmetrical  lesions).^ 

ETIOLOGY 

The  connection  between  trauma  and  syphilis  is  best  illus- 
trated by  lesions  of  bone.  One  sees  gumma  follow  a  contusion, 
the  kick  of  a  horse,  the  application  of  a  set  of  false  teeth,  and 
other  equally  obvious  examples  of  cause  and  effect.  And  the 
impression  founded  upon  such  observations  is  fortified  by 
estimation  of  the  relative  frequency  of  involvement  of  the 
various  bones.  \\\\\\  the  tibia,  the  bone  most  subject  to  trauma, 
easily  first,  and  such  subcutaneous  bones  as  the  parietals,  fron- 
tals,  sternum,  clavicles,  etc.,  following,  there  is  doubtless  some 
connection  between  the  position  of  a  bone,  subjecting  it  to  the 
possibility  of  trauma,  and  the  occurrence  of  syphilis  in  it.  Add 
to  this  the  fact  that  the  lesions  are  chiefly  periosteal,  that  they 
usually  occur  upon  the  surface  of  the  bone  most  exposed  to 
trauma  (e.  g.,  anterior  surface  of  the  tibia,  exterior  surface 
of  the  cranial  bones)  and  the  picture  is  complete.  But  in  most 
instances  the  direct  connection  between  trauma  and  syphilis 
cannot  be  established,  and  surely  of  the  many  bruised  shins 
few  become  syphilitic. 

1  Excepting  the  cranial  bones. 

2  Counting  bilateral  lesions  as  one. 

3  The  distribution  of  unique  lesions  is  sho^\Tl  in  the  table. 


PATHOLOGY 


427 


Mercury  injures  the  bones  only  inasmuch  as  very  severe 
saHvation  may  destroy  portions  of  the  alveolar  processes  of 
maxilla  or  mandible. 


Fig.  52. — Syphilitic  Periostitis  (Hereditary)  of  Shafts  of  Tibia  and  Fibula. 
Note  gradual  transition  from  healthy  bone  at  malleolus  to  indefinite  osteo- 
sclerosis above.  Note  narrowing  of  medullary  canal.  (Case  of  Dr.  Jaeger. 
Skiagraph  by  Dr.  Cole.) 

PATHOLOGY 

The    lesions    of    bone    syphilis,    in    order    of    their    fre- 
quency, are : 


428 


SYPHILIS    OF    BONE 


Osteoperiostitis. 

Gummatous  osteoperiostitis. 

Osteomyelitis. 

Osteoperiostitis. — The  lesion  begins  with  exudation  into 
the  deeper  layers  of  the  periosteum,  thence  it  extends  inward, 
invading  the  bone,  and  to  a  less  degree  outward,  invading  the 
overlying  soft  tissues. 


Fig.  53.— Osteoperiostitis  (Hereditary)  of  Carpus  and  to  a  Less  Degree 
OF  Radius  and  Ulna.  The  carpus  is  utterly  blurred,  but  in  radius  and  ulna 
the  diffuse  irregular  thickening  of  the  periosteum  \\-ith  osteosclerosis  (ulna) 
is  typical.     (Case  of  Dr.  Jaeger.     Skiagraph  by  Dr.  Cole.) 


PATHOLOGY 


429 


The  invasion  of  the  bone  takes  place  by  way  of  the  ves- 
sels :  the  Haversian  canals  are  filled  with  small,  round  cells ; 


Fig.  54. — Saber  Tibia  of  Hereditary  Syphilis.  Diffuse  osteosclerosis  of  shaft 
of  tibia  projecting  outward  and  also  encroaching  upon  the  medullary  canal. 
This  lesion  is  quiescent  and  does  not  show  the  Hght  thick  periosteal  shadow  as 
an  active  lesion  (Figs.  52,  53)  does.  (Case  of  Dr.  Jaeger.  Skiagraph  by  Dr. 
Cole.) 

the  intervening  layers  of  bone  are  eroded,  and  may  disappear 
through  absorption  (rarefying  osteitis)  or  necrosis. 

These  processes  may  be  diffused  over  a  considerable  area 


43° 


SYPHILIS    OF    BONE 


Fig.  55. — Tibial  Node  of  Acquired  Syphilis. 
Compare  with  Fig.  44.  (Townsend,  in 
"  Morrow's  System.") 


or  quite  sharply  local- 
ized (Figs.  52  to  55). 
In  my  experience,  the 
diffused  process  is  com- 
monest at  the  inner  end 
of  the  clavicle,  the  lo- 
calized process  in  the 
shaft  of  the  tibia. 

When,  in  the  course 
of  time  or  through 
the  effect  of  treatment, 
the  inflammation  di- 
minishes or  tends  to 
heal,  this  tendency 
shows  itself  by  the 
production  of  new 
bone  either  around  or 
throughout  the  region 
affected  by  rarefying 
osteitis.  This  prodiic- 
■tive  osteitis  originates 
both  in  the  periosteum 
and  in  the  bone  tissue 
proper  (Figs.  52,  53). 
It  results  in  an  over- 
growth of  very  dense, 
eburnated  bone  tissue, 
which  projects  from 
the  surface  of  the  bone 
in  the  form  of  a  node  ^ 
(exostosis),  and  if  se- 
vere  often    obliterates, 


'  A  very  small  node  is  called  an  osteophyte,  a  very  diffuse  node  a  hyperostosis. 


PATHOLOGY  431 

or  at  least  constricts,  the  medullary  canal,  as  shown  by  skia- 
graph. 

When  the  process  is  diffuse,  the  intermingling  of  rarefy- 
ing and  productive  osteitis  C[uite  destroys  the  regularity  of  the 
bony  outline  and  throws  an  X-ray  shadow  characteristic  of 
syphilis. 

Prognosis. — The  inflammation  may  be  checked  ( i )  in  the 
early  stages  before  any  notable  change  in  the  bone  has  oc- 
curred, in  which  case  there  remains  no  trace;  or  (2)  in  the 
stage  of  localized  or  diffuse  osteitis,  in  which  case  there  re- 
main an  exostosis  or  an  irregular  hyperostosis  to  attest  its 
passage;  or  (3)  it  may  progress,  rapidly  or  slowly,  to — 

Gummatous  Osteoperiostitis.— This  process  is  a  gumma- 
tous degeneration  occurring  in  an  area  of  rarefying  osteitis. 
When  the  gumma  once  begins,  it  softens  rapidy,  soon  involves 
the  overlying  tissues,  and,  if  the  bone  is  near  the  surface  of 
the  body,  involves  and  breaks  through  the  skin,  just  as  does 
the  subcutaneous  gumma. 

Meanwhile  productive  osteitis  occurs  in  a  cup  shape,  sur- 
rounding the  gumma   (Fig.  56). 

Bone  gumma  may  be  single  or  multiple,  and  may  be  asso- 
ciated with  diffuse  osteoperiostitis. 

Prognosis. — The  gumma  may  be  cured  either  (i)  at  its 
inception  before  the  superficial  tissues  have  been  invaded,  in 
which  case  there  results  a  depressed  area  in  the  bone  surrounded 
by  an  irregular  ridge,  but  not  adherent  to  the  skin;  or  (2) 
after  the  overlying  and  skin  tissues  have  been  involved,  in 
which  case  the  skin  (or  scar,  if  the  skin  has  been  destroyed 
by  ulceration)  is  adherent  over  the  depressed  bone,  and  the 
loss  of  tissue  in  the  soft  parts  accentuates  the  depth  of  the 
depression  and  the  height  of  the  surrounding  ridge  of  ebur- 
nated  new  bone. 

Osteomyelitis. — Syphilitic  osteomyelitis  is  extremely  rare 
in    acquired    syphilis.       Certain    early    osteocopic    pains    are 


432 


SYPHILIS   OF    BONE 


apparently  due  to  exudative  lesions  within  the  bone,  but  this 
has  not  been  proven.     Gummatous  osteomyelitis  produces  the 


Fig.  56. — Gumma  of  Inner  Condyle  of  FEiiuR  and  Outer  Condyle  of  Tibia 
(Hereditary  Syphilis):  Arthritis.  (Compare  normal  joint.)  (Case  of 
Dr.  Jaeger.     Skiagraph  by  Dr.  Cole.) 


same  lesions,  mutatis  mutandis,  as  does  gummatous  osteo- 
periostitis. The  strength  of  the  bone  may  be  so  weakened  as 
to  permit  "  spontaneous  "  fracture. 


SYMPTOMS  433 


SYMPTOMS 


Medullary  Lesions. — These  are  so  uncommon  that  their 
symptoms  have  not  been  thoroughly  studied,  except  in  refer- 
ence to  hereditary  syphilis. 

In  acquired  syphiHs  they  show  themselves  under  one  of 
four  chnical  types : 

1.  Osteocopic  pains,  deep-seated,  without  periosteal  swell- 
ing or  tenderness,  and  with  typical  nocturnal  exacerbations. 

2.  "  Spontaneous  "  fracture  may  be  the  first  evidence  of 
medullary  syphilis.  After  the  event  one  may  notice  absence 
or  diminution  of  crepitation  when  the  fragments  are  brought 
in  contact,  and  later  a  gummatous  tumor  enveloping  them. 
If  the  diagnosis  is  not  made  and  antisyphilitic  treatment 
promptly  instituted,  union  will  not  occur  and  the  gumma  will 
extend.  Under  mixed  treatment,  however,  such  fractures  heal 
kindly,  though  usually  with  considerable  permanent  deform- 
ity due  to  absorption  of  bone. 

3.  Non-union  of  a  traumatic  fracture  may  be  caused  by 
syphilis.  Of  the  thousands  of  syphilitics  whose  bones  are 
broken,  very  few  show  anything  abnormal  in  the  process  of 
repair.  But,  exceptionally,  one  meets  a  case  of  fracture  about 
which  there  is  nothing  unusual,  except  that  the  patient  has 
had  syphilis,  and  the  fracture  fails  to  unite.  No  large  gumma 
develops  at  the  point  of  injury;  but  if  the  bone  ends  are  cut 
down  upon  they  are  found  eburnated  and  eroded.  A  skiagraph 
should  show  typical  rarefaction  and  eburnation. 

4.  The  gumma  may  eat  through  the  hone  and  extend  from 
its  surface  as  though  it  were  a  periosteal  lesion  (see  below), 
without  causing  severe  pain  or  spontaneous  fracture. 

Periosteal  Lesions. — The  onset  of  all.  osteoperiosteal 
lesions  is  the  same  whether  the  process  is  to  terminate  with  or 
without  gummatous  degeneration. 

The  onset  is  marked  by  pain,  tenderness,  and  swelling. 


434  SYPHILIS   OF    BONE 

The  pain  is  usually  quite  severe,  with  marked  nocturnal  exac- 
erbations less  by  day  and  relieved  by  exercise.  The  tender- 
ness is  localized  and  marked.  The  szvelling,  though  not  always 
recognizable  in  the  milder  lesions,  is  the  best  index  of  progno- 
sis. Marked  and  rapidly  progressive  swelling  shows  active 
disease  with  tendency  to  gummatous  change,  while  slight  or 
stationary  swelling  shows  that  central  degeneration  is  not 
threatening — that  the  lesion  tends  to  follow  the  milder  pro- 
ductive type. 

Following  upon  such  an  onset,  the  disease  establishes  itself 
either  as  a  productive  osteoperiostitis  or  a  destructive  gumma. 
Besides  these  two  types,  there  is  a  "mixed  "  type  due  to  gum- 
matous degeneration  in  an  area  of  osteoperiostitis. 

Osteoperiostitis. — The  lesion  as  a  rule  develops  very 
slowly.  When  once  established,  this  shows  itself  as  a  thick- 
ening of  the  bone.  It  is  usually  situated  near  the  extremity 
of  a  long  bone  (tibia,  clavicle,  ulna),  and  is  diffuse,  irregular, 
insensitive,  and  without  subjective  symptoms.  Such  a  deform- 
ity simulates  nothing  else  than  an  exuberant  callus,  following 
fracture,  from  which  it  may  be  readily  distinguished  by  the 
history.  The  patient  usually  attributes  the  pain  at  the  onset 
to  some  imaginary  injury,  unless  it  is  so  slight  as  not  to  have 
attracted  his  notice;  in  which  case  he  states  that  he  has  just 
discovered  the  bony  growth,  which,  as  a  matter  of  fact,  has 
been  silently  growing  for  months. 

But  almost  every  symptom  of  such  a  typical  case  may  vary. 
The  lesion  may  be  situated  upon  the  skull  or  near  the  center 
of  a  long  bone ;  it  may  be  circumscribed,  sensitive,  tender,  and 
even  accompanied  by  reddening  and  edema  of  the  superficial 
tissues,  as  in  gumma. 

Periosteal  Gumma. — This  lesion  usually  follows  an 
acute  course  in  marked  contrast  to  the  chronicity  of  productive 
osteoperiostitis.  The  onset  is  usually  sharp,  exceptionally  sub- 
acute, with  little  pain  and  tenderness. 


SYMPTOMS  435 

The  swelling,  which  may  be  obscured  by  the  deep  situation 
of  the  bone  (spine,  femur),  is  at  first  a  flattened,  hard,  circum- 
scribed, tender  swelHng  attached  to  the  bone.  As  it  grows,  it 
becomes  softer ;  the  tissues  over  it  first  adhere,  then  become 
edematous,  and  finally  involved  in  the  gumma.  In  its  subcu- 
taneous situations  (tibia,  cranial  bones)  periosteal  giimma 
passes  through  precisely  the  same  clinical  phases  as  does  sub- 
cutaneous gimima  (page  32"/),  except  that  it  is  from  the  begin- 
ning adherent  to  and  in  some  measure  incorporated  in  the 
bone. 

When  the  bone  is  deep-seated,  the  gumma  usually  reaches 
the  stage  of  softening  and  considerable  involvement  of  the 
overlying  soft  parts  before  it  is  diagnosed. 

Destruction  of  the  hone  by  gumma  occurs  in  two  ways.  In 
part  the  bone  is  actually  eaten  away  and  absorbed;  in  part  its 
circulation  is  cut  off,  and  the  fragment  is  thrown  off  as  a 
sequestrum.  Hence  at  the  bottom  of  an  ulcerated  bone  gumma 
there  may  be  fragments  of  dead  bone.  These  are  usually  few 
and  small;  large  fragments,  requiring  surgical  judgment  as  to 
the  time  and  surgical  skill  as  to  the  manner  of  their  removal, 
are  extremely  rare. 

A  more  important  result  of  bone  destruction  is  the  com- 
plete absorption  of  a  phalanx  by  a  severe  syphilitic  dactylitis. 
(Fig.  58).  Whether  the  phalanx  is  absorbed  by  rarefying 
osteitis  or  necrosed  and  cast  off  as  a  secjuestrum,  the  result 
is  the  same;  with  healing  the  soft  parts  contract  and  almost 
completely  obliterate  the  phalanx,  leaving  a  shortened,  dis- 
torted finger. 

Bone  syphilis  in  children,  whether  acquired  or  hereditary, 
has  a  peculiar  afiinity  for  the  epiphyseal  cartilages  of  the  long 
bones  and  the  cranial  sutures.  The  resultant  deformities 
(pseudo-paralysis,  shortening  or  lengthening  of  the  long  bones, 
natiform  skull,  etc.)  are  discussed  with  the  lesions  of  hered- 
itary syphilis  (page  518). 

30 


436  SYPHILIS    OF    BONE 

Complications. — True  suppuration  in  a  syphilitic  lesion  of 
bone  is  very  rare,  although  the  syphilitic  bone  lesion  may  be 
so  acute  as  to  cause  a  slight  rise  of  temperature  which,  with 
the  redness,  swelling,  and  tenderness,  may  well  give  the  im- 
pression of  suppuration. 

DIAGNOSIS 

The  nocturnal  pains  (if  present),  the  characteristic  course 
of  the  disease,  whether  productive  or  gummatous,  and  the 
other  evidences  of  syphilis  usually  establish  the  diagnosis.  In 
doubtful  cases  the  X-ray  confirms  or  rejects  this  diagnosis, 
by  showing  an  area  of  rarefaction  surrounded  by  an  area  of 
condensation  or  irregularly  intermingled  spots  of  the  two, 
typical  of  syphilis   (Figs.   52  to  55). 

Differential  Diagnosis. — Bone  syphilis  may  be  mistaken 
for  suppurative  periostitis  or  osteomyelitis,  tuberculosis,  neo- 
plasm, and  exuberant  callus.  The  X-ray  must  be  used  to  diag- 
nose obscure  cases. 

Suppurative  Bone  Lesions. — Though  an  active  perios- 
teal gumma  may  show  all  the  local  signs  of  suppuration,  there 
is  little  or  no  fever,  little  leukocytosis,  and  the  characteristic 
night  pain  to  guide  one.  If  an  X-ray  is  not  accessible,  explora- 
tory puncture  or  incision  withdraws  a  sero-sanious  fluid  imme- 
diately suggestive  of  syphilis,  while  the  boggy  fluctuation  is 
undiminished. 

Tuberculosis. — Syphilis  of  joints  is  often  mistaken  for 
tuberculosis,  syphilis  of  bone  hardly  ever;  their  clinical  char- 
acteristics are  quite  distinct.  The  lesions  of  tuberculosis  are 
situated  in  the  epiphysis  rather  than  in  the  shaft ;  the  pain  of 
tuberculosis  does  not  show  severe  nocturnal  exacerbation,  and 
is  relieved  by  traction  while  that  of  syphilis  is  not. 

If  a  large  gumma  is  mistaken  for  cold  abscess,  puncture  or 
incision  promptly  rectifies  the  error. 


TREATMENT  AND  PROGNOSIS  437 

Neoplasm. — The  X-ray  is  by  far  the  best  diagnostic  aid. 
Without  it  one  may  have  to  depend  upon  exploration. 

Callus. — As  already  noted,  irregular  masses  of  old  osteo- 
periostitis may  simulate  exuberant  callus,  a  history  of  injury 
being  imagined  to  fit  the  case.  History  and  X-ray  establish  the 
diagnosis. 

TREATMENT  AND  PROGNOSIS 

Treatment. — The  treatment  of  bone  syphilis  shows  the 
iodids  to  the  best  advantage.  It  is  upon  them  that  we  chiefly 
depend,  although  it  is  impossible  to  state  in  exact  terms  how 
much  iodid  will  be  required  to  control  any  given  lesion.  The 
most  active  gtmima  may  yield  promptly  to  a  very  small  dose, 
while  a  very  sluggish  and  apparently  superficial  periosteal 
thickening  may  require  prolonged  treatment  by  high  doses. 
Such  obstinate  cases  should  be  treated  after  the  rules  laid  down 
for  the  treatment  of  nervous  syphilis  by  interrupted  courses, 
alternating  mixed  treatment  with  hygiene. 

The  use  of  mercury  in  the  treatment  of  bone  syphilis  some- 
times seems  superfluous,  yet  it  is  surely  of  great  assistance 
in  preventing  relapses  and  in  eradicating  the  last  remainder 
of  the  syphiloma. 

The  local  treatment  of  bone  syphilis  is  relatively  unimpor- 
tant. The  application  of  a  mercurial  ointment  or  plaster  to  a 
lesion  that  has  not  already  ulcerated  through  the  skin  some- 
what retards  its  growth;  but  one  should  beware  lest  the  oint- 
ment irritate  the  skin  and  so  reduce  its  vitality  as  to  encourage 
its  destruction  by  the  gumma. 

After  ulceration  has  occurred  it  is  necessary  to  keep  the 
lesion  clean,  and  for  this  purpose  a  powder  consisting  of  one 
part  of  calomel  to  two  of  talcum  is  useful,  though  for  dispen- 
sary patients  applications  of  blue  ointment  are  commonly 
employed.  * 

If  there  is  considerable  cellulitis  or  any  tendency  to  sup- 


438  SYPHILIS    OF    BONE 

piiration,  these  must  be  combated  by  the  usual  wet  dressings 
employed  in  surgery. 

If  the  ulcer  is  old  or  extensive,  it  should  be  carefully 
probed  for  dead  bone;  but  the  surgeon  must  resist  as  far  as 
possible,  the  temptation  to  remove  such  dead  bone  by  operation 
with  the  idea  of  hastening  healing,  for  demarcation  occurs  very 
slowly,  and,  if  the  removal  of  a  semidetached  piece  of  bone  is 
attempted,  this  may  result  either  in  leaving  behind  bone  which 
will  subsequently  necrose  or  in  stirring  up  the  lesion  to  re- 
newed activity.  The  best  plan  is  to  push  systemic  treatment 
and  not  to  attempt  the  removal  of  sequestra  until  they  are 
freely  movable.  The  only  exception  to  this  rule  is  the  case  in 
which  a  large  sequestrum  encourages  suppuration,  especially 
if  it  be  in  a  cranial  bone.  For  such  a  case  prompt  operation 
is  indicated  for  the  removal  of  the  sequestrum.^ 

Prognosis. — The  prognosis  depends  almost  entirely  upon 
the  treatment.  Bone  lesions,  however  shocking  in  appearance, 
are  marvelously  amenable  to  medication  with  the  iodids.  But 
if  the  lesion  is  untreated,  it  is  impossible  to  foretell  in  the 
beginning  how  far  it  will  go  or  exactly  what  character  it  will 
assume ;  whether  it  will  be  diffuse  or  circumscribed,  productive 
or  destructive. 

If  treatment  is  begun  at  the  onset,  the  lesion  may  be  cured 
and  practically  no  scar  remain.  If  a  productive  periosteal 
lesion  has  already  formed  exostosis  or  hyperostosis  before  it 
is  controlled  by  treatment,  we  may  not  expect  to  reduce  these 
deformities  any  more  than  to  dissolve  the  bones  themselves. 

Thus  when  a  patient  presents  himself  with  extensive,  irreg- 
ular enlargement  of  a  bone,  and  examination  shows  this  en- 
largement to  be  insensitive  while  the  X-ray  reveals  it  to  be 
composed  of  dense,  eburnated  bone,  the  patient  should  be  put 
upon  a  mild  course  of  mixed  treatment  in  order  to  eliminate 

1  Voss,  Dermat.  Zeitschr.,  1905,  vol.  xii. 


LESIONS   OF   SPECIAL    BONES 


439 


any  possible  remaining  active  process  within  this  bone  and  to 
minimize  the  probabihty  of  relapse;  but  he  should  not  be  en- 
couraged to  expect  from  any  treatment  the  reduction  of  this 
permanent  deformity. 

The  only  stage  at  which  bone  syphilis  demands  immediate 
heroic  treatment  is  when  a  gumma  is  developing  rapidly  and 
threatening  to  soften  or  to  break  through  the  skin.  Under 
such  conditions  iodid  should  be  pushed  rapidly  in  the  hope  of 
preventing  the  scar  which  will  result  if  the  skin  is  broken. 
But,  even  though  such  lesions  are  brought  rapidly  under  con- 
trol, the  unbroken  skin  may  be  left  thinned  and  adherent  to  the 
underlying  bone  and  leave  a  scar  almost  as  disfiguring  as  if 
ulceration  had  occurred. 

LESIONS    OF    SPECIAL    BONES 

The  preceding  description  applies  to  bone  syphilis  in  gen- 
eral, but  the  lesions  of  certain  special  bones  show  peculiar  char- 
acteristics that  merit  some  attention.  We  may  note  par- 
ticularly the  lesions  of  the  cranial  bones,  of  the  fingers,  of  the 
inferior  maxilla,  of  the  sternum,  and  of  the  vertebral  column. 

Cranial  Bones. — Syphilitic  lesions  of  the  cranial  bones 
commonly  affect  the  frontals  and  the  parietals.  They  are  often 
multiple,  are  usually  gummatous  in  character,  and,  as  a  rule, 
begin  in  the  periosteum  covering  the  external  table,  though 
they  may  originate  in  the  diploe  or  upon  the  internal  table. 

When  projecting  externally,  these  lesions  show  no  very 
peculiar  characteristics  except  their  disfiguring  character  (great 
swellings  upon  the  head),  and  the  rapidity  with  which  they  eat 
into  the  bone,  leaving  it  riddled  and  worm-eaten,  as  shown 
in  Fig.  57. 

When  they  project  within  the  cranium,  however,  whether 
beginning  on  the  internal  surface  or  in  the  diploe,  or  having 
eaten  through  the  whole  bone  from  the  external  surface,  they 


440 


SYPHILIS    OF    BONE 


promptly  involve  the  meninges,  and  thence  the  brain,  causing 
localized  headache  and  epileptiform  convulsions,  according  to 
the  region  of  the  brain  involved. 

If  the  lesion  is  entirelv  internal,  there  may  be  no  external 
manifestation  beyond  a  certain  tenderness  to  pressure,  and  later, 


^ij«J 


Fig.  57. — Extensive  Gummatous  Destruction  of  Skull.     (Lebert.) 

as  the  bone  becomes  eaten  away,  a  crackling  of  the  outer  shell, 
as  this  yields  under  the  finger. 

If,  on  the  other  hand,  the  bone  has  been  eroded  and  the 
skin  ulcerated,  rapidly  fatal,  septic  meningitis  may  result, 
though  it  is  surprising  how  frequently  even  these  cases  resist 
infection. 


LESIONS    OF    SPECIAL    BONES 


441 


Syphilitic  Dactylitis. — Syphilis  of  the  phalanges  may  at- 
tack one  or  more  fingers  or  toes.  It  is  usually  single,  and 
attacks  the  index  or  middle  finger.  The  proximal  phalanx  is 
almost  always  the  one  attacked  (Fig.  58).  The  toes  are  much 
less  frequently  afifected  than  the  fingers. 

As  Taylor  has  shown,  the  lesions  of  syphilitic  dactylitis 
may  begin  in  any  of  the  tissues  of  the  fingers,  but  it  usually 
involves  the  whole  of  the  phalanx,  beginning  as  a  periosteal 
lesion  or  as  an  osteomyelitis.  Taylor  states  that,  if  the  process 
begins  in  the  soft  parts,  there  is  simply  a  chronic  fusiform  thick- 
ening of  all  the  tissues  of  the  finger,  the  bone  finally  becoming 


Fig.  58. — Syphilitic  Dactylitis.     (Piffard.) 


involved;  and  this  involvement  of  the  bone  beginning  near  the 
metacarpo-phalangeal  joint. 

In  the  more  common  form  of  dactylitis  that  begins  in  the 
bone,  the  external  appearance  is  very  much  the  same.  The 
finger  is  swollen  but  not  reddened,  and  the  process  exists  a 


442  SYPHILIS    OF    BONE 

long  time  before  gummatous  softening  and  ulceration  occur. 
Indeed,  in  some  cases,  spontaneous  resolution  may  terminate 
the  inflammation. 

Taylor  states  that  the  progress  of  syphilitic  myelitis  is 
much  more  rapidly  destructive  than  that  of  periostitis. 

All  of  these  lesions  are  much  more  common  in  children 
than  in  adults,  and  therefore  are  usually  seen  in  hereditary 
rather  than  in  acquired  syphilis. 

On  account  of  the  youth  of  the  patient  and  the  relative 
painlessness  of  the  inflammation  the  process  is  often  neglected 
for  many  months,  and,  as  a  result,  the  phalanx  may  be  greatly 
disfigured,  either  by  destruction  of  the  shaft  of  the  bone  or 
by  implication  of  the  joints  at  either  extremity.  But  when 
seen  early,  it  yields  quite  as  readily  as  does  any  other  form  of 
bone  syphilis. 

Inferior  Maxilla.  — The  lower  jaw  may  be  affected  by 
osteoperiostitis  or  by  gumma  in  any  or  all  of  its  parts.  But 
the  common  lesion  is  destructive  of  a  portion  of  the  alveolar 
border  by  acute  gvmimatous  inflammation.  The  process  is  sim- 
ilar to  necrosis  of  the  palate  and  nasal  septum. 

The  lesion  begins  with  a  swelling  around  the  root  of  one 
or  more  teeth.  These  soon  become  loose,  and  then  in  a  few 
days  or  weeks  a  portion  of  the  alveolar  process  is  shed  and 
the  loosened  teeth  fall  with  it.  Exceptionally,  the  inflamma- 
tion may  be  checked  with  loss  of  little  or  no  bone  and  with  a 
resultant  deformity  in  the  gum,  which  may  not  seriously  impair 
the  vitality  of  the  adjacent  teeth;  but,  as  a  rule,  even  if 
attacked  early,  one  may  expect  to  lose  at  least  one  tooth. 

Of  the  three  cases  of  syphilis  of  the  upper  jaw  which  I 
have  recorded,  two  were  of  this  same  nature,  i.  e.,  necrosis  of 
the  alveolar  process;  the  third  was  a  gumma  in  the  antrum. 

Sternum. — In  early  sj^philis  tenderness  of  the  sternum,  due 
to  periostitis  and  excited  by  tapping  upon  that  bone,  is  only 
less  common  than  tenderness  of  the  shins.     But  the  later,  more 


LESIONS    OF    SPECIAL    BONES  443 

serious  lesions  of  the  sternum  are  far  less  common.  There 
may  be  osteoperiostitis  or  periosteal  gimiina,  or  gumma  of  the 
diploe. 

The  chief  and  most  important  peculiarity  of  these  lesions 
is  that  when  they  begin  on  the  internal  surface  of  the  bone, 
or  extend  thereto,  they  may  invade  the  anterior  mediastinum 
and  cause  various  symptoms,  such  as  pericardial  pain,  attacks 
of  dyspnea,  asthma,  angina,  or  circulatory  disturbances,  on 
account  of  pressure  or  of  involvement  of  the  pericardium  or 
pleura. 

Vertebral  Column. — Lesions  of  the  vertebral  column  are 
extremely  rare.  They  have  been  most  often  recorded  in  the 
cervical  and  in  the  dorsal  region.  Most  of  the  cer\'ical  lesions 
are  due  to  gumma  of  the  posterior  pharyngeal  wall,  whether 
primarily  periosteal  or  submucous. 

The  lesions  are  almost  always  found  in  the  bodies  of  the 
vertebra,  though  syphilis  of  the  transverse  and  spinous  proc- 
esses has  been  recorded.  The  lesion  assumes  one  of  the  fol- 
lowing clinical  types : 

1.  Pain. — Localized  pain,  often  accompanied  by  sensitive- 
ness and  with  the  typical  nocturnal  exacerbation,  is  the  com- 
monest symptom,  and  may  stand  alone  for  many  months. 

2.  Syphilitic  pseudo-Pott's  Disease. — Syphilis  may  imitate 
Pott's  disease  of  the  spine  very  closely,  destroying  the  bodies 
of  one  or  more  vertebrae,  causing  pain,  anchylosis,  deformity, 
secondary  cold  abscess  (gumma)  formation,  with  exudation 
of  fragments  of  bone  and  secondary  invasion  of  the  cord. 
Such  lesions  occur  almost  exclusively  in  children,  and  may  be 
diagnosed  from  tuberculosis  of  the  spine  by  the  evidences  of 
other  syphilitic  lesions  in  the  child  or  in  its  parents ;  which  evi- 
dence is  fortified  by  the  beneficial  effect  of  antisyphilitic  treat- 
ment. 


CHAPTER    XXIX 

SYPHILIS  OF  JOINTS,  MUSCLES,  TENDONS  AND  APONEU- 
ROSES,  BURS^  AND    TENDON  SHEATHS 

SYPHILIS    OF    THE    ARTICULATIONS 

Syphilis  simulates  every  joint  disease  from  rheumatism  to 
tuberculosis.  Its  lesions  may  be  classified  under  the  following 
types : 

Arthralgia. 

Hydrarthrosis. 

Pseudo-rheumatism. 

Tertiary  arthritis  and  osteoarthritis. 

Deforming  arthritis. 

Syphilitic  Arthralgia. — The  special  characteristics  of  syphi- 
litic arthralgia  are : 

1.  There  is  no  discoverable  lesion  sufficient  to  account  for 
the  pain. 

2.  Nocturnal  exacerbation  and  relief  by  exercise. 

3.  Frequent  in  larger  joints  (shoulder,  knee,  elbow),  rare 
in  smaller  ones ;  if  polyarticular,  one  joint  is  usually  much 
more  painful  than  any  other. 

4.  Common  with  first  onset  of  secondary  symptoms;  rare 
later. 

5.  Unaffected  by  mercury;  promptly  relieved  by  small  doses 
of  iodid. 

Little  need  be  added  to  this  brief  characterization  unless 

it  be  the  statement  that  the  pain  varies  greatly  in  intensity  and 

may  not  show  the  typical  nocturnal  exacerbation.    Thus  I  have 

recently  been  treating  a  man  who,  in  the  third  year  of  his  dis- 

444 


SYPHILIS    OF   THE   ARTICULATIONS  445 

ease,  and  while  under  systematic  mercurial  treatment,  has  per- 
sistently complained  of  slight  and  indescribable  sensations 
about  the  left  knee.  No  objective  signs  of  disease  could  be 
elicited,  and  the  discomfort  continued  for  fully  six  months 
until  he  was  put  upon  potassium  iodid,  gr.  v,  t.i.d.  In  two 
days  the  discomfort  disappeared. 

Hydrarthrosis. — Syphilitic  hydrarthrosis  consists  of  a  pain- 
less joint  effusion.  It  is  quite  rare.  It  is  scarcely  ever  seen 
except  in  the  knee.  If  slight,  the  patient  may  overlook  it ;  even 
if  marked,  it  is  rapidly  absorbed  under  iodic  medication. 

The  absence  of  trauma  and  of  all  sensitiveness  differen- 
tiates it  from  the  ordinary  traumatic  hydrarthrosis.  .  More- 
over, it  occurs  almost  always  in  the  first  months  of  syphilis 
and  in  connection  with  other  lesions  of  the  disease. 

Syphilitic  Pseudo  -  rheumatism. — "  Secondary  pseudo- 
rheumatic  arthropathy  "  (Fournier)  is  extremely  rare.  It  sim- 
ulates acute  articular  rheumatism  in  its  local  symptoms  (heat, 
swelling,  pain,  tenderness,  redness),  but  it  usually  strikes  only 
one  joint,  never  more  than  two  or  three.  The  knee  is  the  joint 
most  often  affected,  the  wrist,  elbow,  and  ankle  less  frequently. 

The  notable  distinction  between  syphilitic  and  true  rheu- 
matism consists  in  the  absence  of  systemic  disturbance  or  of 
generalization  in  the  former.  There  is  never  much  fever,  usu- 
ally none ;  no  sweats ;  no  concentrated  urine ;  no  cardiac  impli- 
cation. Moreover,  the  syphilitic  lesion  is  an  early  one  and 
yields  rapidly  to  iodids. 

Tertiary  Syphilitic  Arthritis. — Tertiary  syphilitic  arthritis 
is  much  more  common  than  the  secondary  hydrops  and  rheu- 
matism just  described.  My  records  show  four  cases  of  sec- 
ondary hydrarthrosis  of  the  knee  during  the  first  year  and  one 
in  knee  and  one  in  elbow  during  the  second,  while  the  tertiary 
lesions  are  distributed  as  follows :  ^ 

>  The  numbers  in  parentheses  indicate  numbers  of  cases  when  more  than  one. 


446  SYPHILIS   OF   JOINTS,   MUSCLES,    ETC. 

Knee,  14  cases  at  one,  four  (2),  five,  six,  seven  (2),  eleven, 
twenty-six,  thirty-three  years. 

Elbow,  5  cases  at  four  (2),  five,  six,  fourteen  years. 

Shoulder,  2  cases  at  seven,  twelve  years. 

Ankle,  2  cases  at  four,  seven  years. 

In  one  case  both  knees  were  involved  at  seven  years ;  in  one 
ankle  and  elbow  were  involved  at  four  years ;  in  one  elbow  and 
knee  at  six  years. 

Pathology. — Tertiary  syphilis  of  the  joints  usually  origi- 
nates in  the  capsule  or  ligaments,  less  often  in  the  bones,  rarely 
in  the  synovial  membrane  or  subserous  tissue. 

In  the  synovial  membrane  the  lesions  are  congestion  and 
the  production  of  warty  excrescences,  especially  in  the  folds 
and  pockets.  The  warty  growths  may  become  fibrous 
and  form  "  joint  mice  "  if  neglected.  There  are  subserous 
infiltrations,  and  perhaps  gummata,  which  open  into  the 
joint.  There  is  always  considerable  effusion.  Long-neglected 
cases  result  in  a  stiff  joint  from  adhesions  of  the  inflamed 
serosa. 

The  cartilages  are  often  the  seat  of  gummata,  which  soften, 
discharge,  and  finally  heal,  leaving  rounded,  depressed  scars 
quite  characteristic  of  syphilis. 

In  the  capsule  there  is  general  thickening  with  circum- 
scribed areas  of  hard,  fibrous  infiltration.  These  are  spoken 
of  as  gummata,  but  they  rarely  break  down. 

The  bone  involvement  is  usually  slight.  In  five  of  the  syphi- 
litic knees  there  was  marked  involvement  of  the  condyles  of 
the  tibia,  in  one  the  femur  was  implicated.  The  lesions  are 
the  usual  osteoperiostitis  or  gumma  (Fig.  56)  ;  a  slight  degree 
of  the  former  is  present  in  all  severe  cases. 

Symptoms- — There  is  painless,  usually  gradual,  enlarge- 
ment of  the  joint  due  in  some  cases  almost  entirely  to  hydrar- 
throsis, in  most  to  the  periarticular  thickening.  The  joint  is 
merely  stiff  and  clumsy.     Examination  reveals  the  thicken- 


SYPHILIS    OF   THE    MUSCLES  447 

ing  of  the  capsule  with  nodules  in  it,  a  certain  amount  of 
effusion,  and  perhaps  some  thickening  of  the  ends  of  the 
bones. 

If  the  papillary  fringes  get  between  the  articular  surfaces 
the  familiar  symptoms  of  the  "  joint  mouse  "  result,  i.  e.,  sud- 
den, excruciating  pain  followed  by  more  or  less  acute  synovitis. 

The  progress  of  the  affection  is  extremely  slow.  If  neg- 
lected it  terminates  in  partial  or  complete  fibrous  ankylosis. 
Frauenthal  ^  states  that  in  neglected  cases  there  is  danger  of 
secondary  tubercular  or  pyogenic  infection. 

Diagnosis. — Syphilis  of  the  knee-joint  is  often  confounded 
with  tuberculosis.  The  diagnosis  can  usually  be  established  by 
the  X-ray;  but  lacking  this  it  must  rest  upon  the  absence,  in 
syphilis,  of  redness,  heat,  fistulse,  and  tenderness ;  the  presence 
of  other  lesions  or  scars  of  syphilis  and  the  effect  of  antisyphi- 
litic  medication. 

Treatment. — While  rest  is  advisable,  it  is  surprising  how 
well  clinic  cases  do  without  it.  The  iodids  are  our  chief  re- 
liance ;  but  it  is  essential  that  repeated  courses  of  treatment  be 
given  for  months  after  the  lesion  is  apparently  cured;  other- 
wise relapse  may  be  expected. 

Deforming  Arthritis. — Trophic  changes  in  the  joints,  espe- 
cially the  knee,  occur  in  tabes,  less  often  in  hereditary  syphilis. 
The  lesion  is  only  indirectly  due  to  syphilis,  and  has  no  pecul- 
iarly syphilitic  characteristics. 

SYPHILIS   OF   THE    MUSCLES 

Apart  from  the  muscle  pains  that  may  occur  in  early  syphi- 
lis (page  263),  syphilis  of  muscles  is  extremely  rare.  I  have 
record  of  only  two  cases,  one  of  torticollis  (sterno-mastoid 
spasm),  one  of  bicipital  contracture. 


'  Med.  Record,  1906,  May  26. 


448  SYPHILIS   OF   JOINTS,    MUSCLES,    ETC. 

The  lesions  described  are : 

Contracture. 

Interstitial  myositis. 

Gummatous  myositis. 

Myositis  ossificans. 

Syphilitic  Contracture. — This  singular  condition  consists 
in  a  gradual  or  sudden  contracture  of  a  muscle  (usually  the 
brachial  biceps  or  triceps).  It  is  painless  so  long  as  no  attempt 
is  made  to  overcome  the  contracture.  It  occurs  almost  exclu- 
sively in  the  first  year  of  the  disease.  Examination  reveals 
the  body  of  the  muscle  to  be  in  a  semiflaccid  condition,  its 
tendon  on  the  stretch,  and  the  joint  to  which  it  is  attached 
absolutely  fixed  by  the  muscular  contracture.  Any  attempt  to 
overcome  this  excites  the  most  vivid  pain,  and  is  futile. 

The  progress  of  this  condition  is  extremely  chronic.  It 
may  get  well  spontaneously,  but  even  under  treatment  it  re- 
solves very  slowly.  The  ultimate  outcome,  however,  is  a  per- 
fect restoration  of  function. 

The  treatment  is  by  mercury. 

Interstitial  Myositis.— Extremely  rare.  The  condition  is  a 
diffuse  infiltration  beginning  in  the  connective  tissue  between 
the  bundles  of  muscle  tissue  and  involving  them  secondarily. 
The  greater  part  of  a  muscle  is  usually  involved.  There  may 
be  gumma.  The  muscle  is  swollen,  dense,  contractured,  and 
slightly  sensitive.  The  skin  may  be  a  little  red,  but  it  is  not 
adherent  nor  is  there  subcutaneous  edema. 

Gumma. — The  first  sign  of  gumma  in  a  muscle  is  slight 
subjective  pain  on  motion  in  a  spot  which  examination  reveals  to 
be  a  sensitive  lump  quite  like  an  induration  of  chronic  myositis. 

But  this  lump  grows  and  becomes  a  definite,  hard  tumor 
within  the  muscle.  It  may  attain  the  size  of  an  orange.  There 
may  be  several  gummata  in  a  single  muscle.  Together  with  the 
gumma  there  may  be  interstitial  myositis  (sclero-gummatous 
type). 


SYPHILIS   OF    BURS^  449 

Finally  it  softens,  invades  the  surrounding  tissues,  and 
bursts  through  the  skin  like  a  subcutaneous  gumma.  Ex- 
ceptionally, instead  of  softening,  it  becomes  sclerosed  or 
ossified. 

The  muscle  most  frequently  afifected  is  the  sterno-mastoid. 

Myositis  Ossificans. — Myositis  ossificans  may  develop  in  a 
patient  who  has  had  syphilis,  and,  very  exceptionally,  an  inter- 
stitial or  gummatous  myositis  degenerates  into  a  bony  growth. 
But  myositis  ossificans  is  scarcely  more  frequent  from  syphilis 
than  from  any  other  sort  of  irritation,  and  postsyphilitic 
myositis  ossificans  does  not  differ  in  symptoms  or  treatment 
from  that  due  to  other  causes;  antisyphilitic  treatment  has  no 
effect  upon  it.^ 

SYPHILIS    OF    TENDONS   AND    APONEUROSES 

Tendons  and  aponeuroses  are  scarcely  ever  involved  except 
by  extension  of  a  syphiloma  from  the  surrounding  parts.  The 
occipito-frontal  aponeurosis  is  said  sometimes  to  be  inflamed 
in  early  syphilis.  I  have  record  of  one  case  of  gumma  of  the 
tendo-Achillis  in  a  patient  with  many  other  tertiary  lesions. 

SYPHILIS   OF    BURS^ 

Acute  bursitis  or  chronic  bursitis  with  effusion  may  com- 
plicate arthritis.     It  is  extremely  rare. 

Gummatous  bursitis  is  far  more  common.  I  have  record 
of  five  cases,  two  of  which  were  published  in  my  father's  mono- 
graph.-    Including  the  cases  therein  collected  by  him  there  are 

1  Perhaps  some  confusion  has  been  injected  into  this  subject  by  the  fact 
that  dense  syphilitic  myositis  of  the  masseter  feels  very  like  bone,  produces 
the  same  contraction  as  would  myositis  ossificans,  and  yet  yields  to  anti- 
syphilitic  treatment. 

2  Am.  J.  Med.  Sci.,  1876,  p.  349. 


450 


SYPHILIS   OF   JOINTS,    MUSCLES,    ETC. 


6  double  (about  the  knees),  13  single:  10  occurred  in  women, 
9  in  men.  Three  occurred  in  the  second  year,  4  between  the 
fifth  and  eighth,  and  i  each  at  fifteen  and  twenty-eight  years 


Fig.  59. — Syphilitic  Prepatellar  Bursitis  with  Involvement  of  the  Over- 
lying Skin.     (Case  of  Dr.  Keyes.     Photograph  by  Dr.  Fox.) 

after  the  chancre.  In  14  cases  the  burs?e  about  the  knee  we^e 
afTected,  usually  the  prepatellar  (Fig.  59). 

The  involvement  of  the  bursas  is  almost  always  primary. 
It  causes  a  considerable  boggy  swelling  (below  the  patella), 
over  which  the  skin  reddens,  thickens  into  great  ridges,  and 
finally  ulcerates. 

The  cure  by  iodid  is  rapid. 


SYPHILIS  OF  THE  TENDON  SHEATHS        451 

SYPHILIS  OF  THE  TENDON  SHEATHS 

Fournier  believes  that  many  of  the  pains  about  the  knees 
and  elbow  at  the  outbreak  of  secondary  symptoms  are  due  to 
tenosynovitis  in  the  neighborhood  of  these  joints.  Acute 
pseudo-inflammatory  tenosynovitis  (with  tenderness,  edema) 
and  chronic  hydrops  are  rare,  but  less  so  than  the  parallel  types 
of  bursitis. 

Gummatous  tenosynovitis  resembles  gummatous  bursitis, 
but  is  even  less  common   (I  have  record  of  but  two  cases). 


31 


CHAPTER    XXX 
SYPHILIS  OF   THE  AIR  PASSAGES^ 

SYPHILIS   OF   THE   LARYNX 

The  larynx  is  not  often  sufificiently  affected  in  early  syphi- 
lis to  produce  symptoms,^  though  laryngoscopic  examination 
reveals  slight  secondary  lesions  in  many  patients  whose  throats 
give  them  no  inconvenience.  Tertiary  lesions,  however,  are 
fairly  frequent  and  quite  distressing. 

Apart  from  the  laryngeal  paralyses  (page  372),  I  have 
record  of  34  cases  of  marked  or  prolonged  syphilitic  aphonia. 
Twenty  of  them  were  about  equally  distributed  in  onset  between 
the  first  and  the  eighth  year,  3  began  in  the  twelfth,  and  i  each 
in  the  eleventh,  seventeenth,  twenty-first,  twenty-fourth,  and 
thirtieth  years  of  the  disease. 

Secondary  Lesions 

The  causes  of  secondary  laryngeal  syphilis  are  abuse  of 
alcohol  or  tobacco  or  overuse  of  the  voice. 

Hence  it  is  much  more  common  among  men  than  among 
women,  among  singers  and  public  speakers  than  among  those 
who  simply  sit  and  listen. 

The  secondary  lesions  are : 
Erythema. 

Mucous  erosions  and  papules. 
Condylomata. 
Diffuse  infiltration. 


'  Reviewed  by  Dr.  L.  M.  Hurd. 

^  Two  cases  of  laryngeal  chancre  have  been  reported. 

452 


SYPHILIS    OF   THE   LARYNX  453 

The  specific  characteristics  of  these  is  that  of  the  same 
lesions  occurring  in  the  mouth  (page  336). 

Laryngeal  erythema  is  much  the  most  common.  It  usually 
occurs  with  the  secondary  outbreak  (or  within  a  few  months 
thereafter).  It  may  be  diffuse  (and  mimic  acute  non-specific 
laryngitis)  or  mottled.  The  inflammation  habitually  involves 
the  epiglottis,  the  false  and  the  true  vocal  cords.  A  mottled 
erythema  of  these  regions  is  almost  pathognomonic  of  syphilis ; 
it  is  the  laryngeal  roseola.  But,  contrary  to  what  one  might 
expect,  this  roseola  is  very  persistent,  and  subsides  spontane- 
ously only  after  many  weeks.  This  mottled  erythema  is  much 
less  common  than  the  diffuse  congestion. 

Either  with  or  without  this  general  erythema,  erosions  or 
superficial  ulcerations  may  appear  in  the  larynx.  Their  seat  of 
election  is  the  true  vocal  cords.  They  are  often  multiple,  and 
appear  as  glistening  or  opalescent  lesions,  set  in  an  area  of  con- 
gestion, occupying  a  part  or  the  whole  of  the  cord. 

Laryngeal  papules,  whether  simple  or  eroded,  are  rare. 

Condylomata  are  equally  rare. 

Diffuse  infiltration  of  the  larynx  is  one  of  those  lesions  that 
might  be  termed  intermediate  between  secondary  and  tertiary 
syphilis.^  It  consists  of  a  more  or  less  diffuse  redness  and 
swelling  usually  confined  to  the  upper  portions  of  the  larynx 
(but  which  may  invade  the  true  cords)  and  usually  unilateral, 
or  at  least  affecting  one  side  of  the  larynx  more  than  the  other. 
The  region  involved  (epiglottis,  false  cords,  etc.)  loses  its 
sharp  contour,  and  appears  reddened,  thickened,  and  bulging. 
The  swelling  is  usually  smooth,  but  may  be  broken  by  little 
pseudo-papules. 

This  lesion,  which  usually  occurs  after  the  first  outbreak 
and  may  appear  several  years  after  the  chancre,  is  slow  to 
develop  and,  even  under  treatment,  extremely  slow  to  disap- 

1  Ulcerative  laryngitis  is  another  such.     I  prefer  to  call  it  tertiary. 


454  SYPHILIS   OF   THE   AIR   PASSAGES 

pear.  It  almost  always  lasts  more  than  a  month,  and  may,  if 
neglected,  lead  to  permanent  thickening  and  aphonia. 

Symptoms. — Aphonia  is  the  cardinal  symptom  of  laryngeal 
syphilis.  The  vocal  disturbance  due  to  secondary  lesions  may 
be  but  a  slight  huskiness  or  a  complete  aphonia,  accompanied 
by  a  dry,  irritative  cough  and  slight  pain  on  deglutition  (if 
the  epiglottis  is  considerably  involved). 

These  symptoms  differ  from  those  of  acute  non-specific 
laryngitis  only  by  their  chronicity.  The  hoarseness  or  aphonia 
does  not  get  well  in  a  few  days,  and  this  brings  the  patient  to 
his  physician. 

Diagnosis. — The  persistent  hoarseness,  combined  with 
symptoms  or  history  of  recent  infection  with  syphilis,  sug- 
gests the  diagnosis,  which  the  laryngoscope  verifies. 

Treatment. — Since  the  hoarseness  is  likely  to  last  several 
weeks  at  best,  several  months  at  worst,  the  treatment  should 
be  vigorous.  Mercury  effects  a  cure,  and  it  is  usually  best  to 
administer  it  by  injection.  lodids  and  local  treatment  are 
useless. 

Tertiary  Lesions 

The  tertiary  lesions  of  laryngeal  syphilis  are : 
Ulceration. 
Gumma. 

Fibroid  degeneration. 
Perichondritis. 
Paralysis. 
Ulcerative  Laryngitis. — This  lesion  resembles  the  ecthy- 
matous  syphilid ;  it  may  be  secondary  or  tertiary,  may  or  may 
not  destroy  tissue,  may  or  may  not  require  iodids  for  a  cure. 
Superficial  syphilitic  ulceration  consists  of  one  or  more 
rounded  or  ovoidal  clean-cut  (but  not  punched-out)  superficial 
ulcers.     They  occur  most  commonly  upon  the  true  cords,  less 
often  on  the  false  cords  or  in  the  interarytenoid  space  (Whis- 


SYPHILIS   OF   THE   LARYNX  455 

tier).  If  numerous  and  situated  upon  the  cords  they  may- 
excite  edema  of  the  glottis.  This  I  have  not  seen;  but  Four- 
nier  says  he  has  several  times  known  it  to  require  tracheotomy. 

When  the  ulcers  heal,  they  usually  leave  permanent  super- 
ficial scars. 

Deep  syphilitic  ulceration,  more  common  than  the  super- 
ficial type,  is  usually  a  malignant,  destructive  lesion.  The  ulcer 
is  deep,  punched  out,  single,  or  multiple,  commonest  upon  the 
epiglottis  and  false  cords.  If  neglected  it  spreads  superficially, 
at  the  same  time  eating  into  the  subjacent  tissues.  Perichon- 
dritis or  edema  of  the  glottis,  acute  or  chronic,  may  supervene 
unless  the  case  is  brought  promptly  under  control. 

The  adhesions  resulting  from  the  cicatrization  of  large 
ulcers  are  as  characteristic  as  those  that  occur  about  the  soft 
palate  under  similar  circumstances.  The  epiglottis  is  adherent 
to  the  base  of  the  tongue  or  to  some  part  of  the  pharynx,  while 
from  below  there  are  adhesions  binding  it  to  the  false  vocal 
cords  and  adjacent  regions.  Dislocation  of  various  parts  of 
the  larynx  may  result  from  cicatricial  contraction,  or  the  whole 
organ  may  be  stenosed ;  a  web  of  adhesions  may  unite  the  vocal 
cords. 

Gumma  of  the  Larynx. — Gumma  of  the  larynx  is  ex- 
tremely rare  unless  one  regards  all  deep  syphilitic  ulcerations 
.as  originating  in  unseen  gummata. 

Gumma  is  almost  always  circumscribed,  single,  and  situ- 
ated in  the  upper  part  of  the  larynx.  It  appears  at  first  as  a 
red  nodule,  which  becomes  yellow  as  it  softens,  then  breaks  and 
follows  the  course  of  deep  syphilitic  ulceration  of  the  larynx. 

Fibroid  Degeneration. — Under  this  title  J.  N.  Macken- 
zie ^  describes  "  a  decided  tendency  to  the  gradual  development 
of  fibroid  tissue  in  the  structure  of  the  larynx,  which  tends  to 
diminish  the  lumen  of  the  organ,  not  only  by  contraction  of  the 
new-formed  tissue,  but  also  by  the  production  of  large,  dense, 

'Morrow's  "System,"  1893,  vol.  ii,  p.  342. 


456  SYPHILIS    OF    THE    AIR    PASSAGES 

fibroid  tumors,  which  are  often  mistaken  for  and  described  as 
gummy  tumors,  but  which  pathologically  have  nothing  in  com- 
mon with  them.  These  fibroid  tumors  appear  as  hard,  nodular 
masses  occupying  the  epiglottis,  aryepiglottic  folds,  and  other 
portions  of  the  vestibule  and  subglottic  region.  Sometimes  the 
greater  portion  of  the  organ  is  converted  into  a  dense  hyper- 
trophic mass.  Acute  ulceration  occurs,  and  is  fraught  with 
great  danger  from  accompanying  edema,  and  each  succeeding 
attack  of  ulceration  favors  a  greater  deposit  of  fibrous  tissue, 
and  increases  proportionately  the  gravity  of  the  case.  In  this 
variety  of  laryngeal  syphilis,  which  Whistler  has  especially 
insisted  upon,  no  retrograde  metamorphosis  takes  place;  its 
processes  are  essentially  progressive,  and  the  caliber  of  the 
larynx  becomes  diminished  sooner  or  later  by  an  irregular  nod- 
ular mass — half-hypertrophied  tissue,  half-cicatricial  bands — 
which  does  not  subside  under  internal  or  local  treatment,  and 
which,  if  extensive,  demands  tracheotomy. 

"  These  fibroid  tumors  may  be  differentiated  from  gummata 
by  their  pale,  grayish  or  whitish  appearance,  by  the  surround- 
ing anemia  of  the  mucous  membrane,  and  by  the  absence  of  the 
peculiar  yellowish  submucous  discoloration  of  the  latter.  The 
hard,  dense  sensation  communicated  to  the  probe  contrasts 
forcibly,  too,  with  the  soft  elastic  feel  of  the  gummy  growth. 

"  This  class  of  case  is  only  seen  in  hospital  or  dispensary 
practice,  and  presents  a  long  history  of  neglected  laryngeal 
trouble  with  gradually  increasing  obstruction  to  respiration." 

Perichondritis. — Perichondritis  (usually  of  the  cricoid  or 
thyroid)  may  be  primary,  but  habitually  results  from  neglect 
of  a  syphilitic  ulcer  or  gumma. 

The  onset  is  slow  and  obscure  with  symptoms  of  moderate 
aphonia  and  hoarseness  and  a  diffuse,  red  swelling  (or  ulcer) 
over  the  cartilage  affected.  But  as  soon  as  necrosis  of  the  car- 
tilage begins,  the  suppuration  about  it  causes  acute  edema, 
which  may  require  intubation  or  tracheotomy. 


SYPHILIS   OF   THE    LARYNX  457 

Even  if  promptly  taken  in  hand,  perichondritis  usually  re- 
sults in  sequestration  of  part  at  least  of  the  cartilage  affected. 
This  implies  prolonged  suppuration  (possibly  pyemia  or  septic 
pneumonia)  and  detachment  of  the  necrosed  fragment.  This 
fragment  is  usually  coughed  up,  but  may  remain  caught  in  the 
larynx  with  fatal  results,  as  in  the  case  of  Labbe :  ^ 

"  The  patient  entered  La  Charite  with  laryngeal  syphilis. 
On  the  sixth  night  after  admission  he  suddenly  died  of  suffo- 
cation before  he  could  be  relieved.  Autopsy  showed  that  the 
right  arytenoid  cartilage  had  fallen  into  the  glottis,  obstructing 
it  completely." 

Laryngeal  Paralysis. — Laryngeal  paralysis  may  be  due 
to  central  lesion,  to  neuritis,  or  to  pressure  upon  the  nerve  by 
enlarged  glands.  The  lesion  is  doubtless  usually  a  central  one, 
though  it  is  not  often  associated  with  other  evidences  of  cere- 
bral syphilis  (page  372). 

Paralysis  of  the  larynx  due  to  syphilis  offers  no  pathog- 
nomonic features  save  its  prompt  reaction  to  mixed  treatment. 
We  need  not,  therefore,  delay  to  describe  it.  It  is  imitated  by 
ankylosis  of  the  arytenoids. 

Symptoms. — Tertiary  laryngeal  syphilis  (paralysis  apart) 
produces  aphonia  chronic  in  character,  variable  in  intensity. 
This  is  the  classical  syphilitic  vox  rauca.  To  it  may  be  added 
pain — in  deglutition  if  the  epiglottis  is  involved,  in  any  effort 
to  use  the  voice  if  there  is  perichondritis  of  cricoid  or  thyroid. 
This  pain  may  be  very  intense,  and  has  been  known  even  to 
prohibit  speech,  and  so  to  discourage  swallowing  that  the 
patient  would  rather  starve  than  suffer  the  pain  of  deglutition. 
Yet  in  the  great  majority  of  cases  the  pain  is  absent  or  neg- 
ligible. Indeed,  the  classical  vox  rauca  of  syphilis  is  a  hoarse- 
ness lasting  for  months  or  years  without  any  pain  whatever. 

'  Quoted  by  Castex  in  Foumier's  "  Traite  de  la  syphilis,"  1906,  vol.  ii, 
Part  II,  p.  677. 


458 


SYPHILIS    OF    THE    AIR    PASSAGES 


Cough,  expectoration,  and  foul  breath  are  evidence  of  ulcer- 
ation. Asphyxiation  may  be  sudden  by  edema  of  the  glottis  or 
by  impaction  of  a  sequestrated  cartilage,  or  it  may  be  a  grad- 
ual obstruction  due  to  the  projection  of  the  diseased  tissue  into 
the  larynx  or  to  adhesions  or  cicatricial  contractions  forming 
as  the  active  lesions  heal. 

Diagnosis. — Secondary  Syphilis. — The  secondary  lesions 
of  syphilis  can  scarcely  be  confused  with  anything  except  acute 
laryngitis.  From  thiis  the  duration  of  the  congestion,  if  not 
its  laryngoscopic  peculiarities,  soon  differentiate  it. 

Tertiary  Syphilis. — The  lesion  must  be  distinguished  from 
tuberculosis  and  from  malignant  neoplasm. 

The  diagnosis,  though  usually  easy  enough,  may  be  ex- 
tremely difficult.  Schnitzler,  Luc,  and  Fournier  maintain  the 
possibility  of  tuberculosis  in  a  syphilitic  larynx. 

The  following  table  contrasts  the  chief  distinguishing  fea- 
tures of  syphilis,  tuberculosis,  and  malignant  neoplasm : 


SYPHILIS 

TUBERCULOSIS 

NEOPLASM 

Number  of  Lesions. — 

Usually  multiple. 

Single. 

Usually  single. 

Usual     Situation. — 

Vocal  cords. 

False  cords. 

Epiglottis. 

Hyperplasia. — Dif- 

Moist, granular,  pink. 

Dark,     bleeding, 

fuse,   dry,  dark  red    or 

bathed   in    mucus;    per- 

vegetating. 

yellowish. 

haps  covered  with  ulcers 
or  with  inflamed  glandu- 
lar orifices,  or  with  yel- 
lowish spots. 

Ulcers. — Deep,  slough- 

Superficial,    granulat- 

Rare; sloughing. 

ing,     eroding,     perhaps 

ing,  multiple. 

Manifestly     subordi- 

disclosing bare  cartilage; 

nate  to  the  neoplasm. 

Usually  single. 

Surrounding  Tissue. — 

Very  pale. 

Red. 

Associated    Lesions. — 

Tubercular. 

Syphilitic. 

Pain. — Rare. 

Usual. 

Usual. 

Pathognomonic     Test. 

Tubercle    bacilli    in 

Biopsy. 

— Treatment. 

sputum. 

SYPHILIS   OF   THE    LARYNX  459 

While  the  chronic  vox  raiica  syphilitica,  lasting  for  years 
and  unaccompanied  by  cough,  pain,  or  expectoration,  is  very 
suggestive  of  syphilis,  it  is  not  absolutely  pathognomonic. 

Prognosis. — The  prognosis  of  laryngeal  syphilis  is  none  too 
good.  Even  the  secondary  lesions  may  permanently  impair  the 
voice,  especially  in  its  singing  quality. 

To  this  danger  the  tertiary  lesions  add  that  of  relapse 
(which  is  relatively  frequent),  acute  edema  of  the  glottis,  deep 
cellulitis  of  the  neck  from  mixed  infection,  chronic  obstruction 
to  respiration  by  adhesions  or  cicatricial  contraction,  if  not  by 
the  growth  itself,  and  possible  acute  suffocation  by  a  detached 
sequestrum,  or  secondary  inoculation  with  tuberculosis. 

Treatment. — The  general  treatment  should  be  vigorous, 
preferably  by  intramuscular  injections  of  mercury  and  (for  the 
tertiary  lesions)  large  doses  of  iodids. 

"  The  local  treatment  of  the  diffused  laryngitis  of  secondary 
syphilis  does  not  differ  materially  from  that  of  simple,  catar- 
rhal laryngitis.  Should  ulceration  occur,  iodoform  may  be 
freely  used.  In  the  deeper  form  of  ulceration  this  drug  is  of 
inestimable  service,  and  is,  in  the  writer's  experience,  superior 
to  iodin  and  the  nitrate  of  silver.  Sprays  of  the  bichlorid  of 
mercury,  or  the  local  application  of  the  yellow  oxid  in  cos- 
molin,  vaselin,  or  like  substance,  are  also  of  considerable  value. 
Before  applying  these  remedies  the  ulcerated  surface  should 
be  thoroughly  cleansed  by  means  of  a  detergent  and  disinfectant 
spray,  for  otherwise  much  of  the  good  effect  will  be  lost. 

"  Papillomatous  growths  may  be  dissipated  by  the  local 
application  of  alcohol  or  chromic  acid,  or,  if  extensive,  may  be 
removed  at  once  with  the  forceps.  Membranous  webs  may  be 
successfully  divided  with  the  galvano-cautery  (Elsberg)  or 
by  cutting  dilators,  the  best  of  which  is  that  devised  by 
Whistler. 

"  Whether  any  good  can  be  accomplished  by  the  division  of 
adhesions  must  be  determined  by  the  peculiarities  of  the  indi- 


460  SYPHILIS    OF    THE    AIR    PASSAGES 

vidual  case.  Except  when  function  can  be  restored,  or  serious 
dyspnea  or  dysphagia  mitigated  by  the  operation,  it  is  better, 
as  a  rule,  to  let  them  severely  alone. 

"  Serious  interference  with  respiration  from  any  complica- 
tion calls  for  tracheotomy,  and  the  early  performance  of  the 
latter  is  especially  to  be  advised  when  the  larynx  has  under- 
gone the  fibroid  degeneration  described  above.  Systematic 
dilatation  of  the  larynx  is  sometimes  of  value,  but,  as  a  rule, 
little  can  be  expected  of  this  line  of  treatment  beyond  tempo- 
rary improvement,  while  it  is  much  inferior  to  the  cutting 
operation. 

"  Loosened  necrotic  plates  of  cartilage,  in  view  of  the  dan- 
gerous complications  to  which  they  may  give  rise,  should  be 
removed,  if  practicable,  by  endolaryngeal  operation  or  from 
without  by  exsection  "  (Mackenzie). 

SYPHILIS    OF    TRACHEA,    BRONCHI,    AND    LUNGS 

Syphilis  of  the  trachea  and  bronchi  is  associated  clinically, 
on  the  one  hand,  with  laryngeal  syphilis,  on  the  other  with 
lung  syphilis;  but  bronchial  or  peribronchial  syphilitic  lesions 
are  entirely  distinct  from  those  beginning  in  the  lung  tissue. 

But  all  of  these  lesions  are  extremely  rare.  (I  have  record 
of  two  cases  of  tracheal  syphilis  at  fourteen  and  twenty-two 
years  after  chancre;  one  case  of  probable  pulmonary  syphilis 
at  fifteen  years.)  Moreover,  the  clinical  picture  of  disease  of 
the  lower  respiratory  organs  due  to  syphilis  is  better  considered 
as  a  whole,  since,  in  many  instances,  lesions  of  one  part  of  the 
respiratory  tract  overshadow  equally  important  changes  in  an- 
other part ;  while  in  many  cases  it  is  impossible  to  prove  during 
life  that  the  lesion  is  syphilitic  or  to  identify  its  exact  site  and 
character. 

Tracheal  and  Bronchial  Lesions. — Secondary  roseola,  ca- 
tarrh, and  mucous  patches  have  been  observed  in  the  trachea. 


SYPHILIS    OF   TRACHEA,    BRONCHI,    AND    LUNGS      461 

and  doubtless  may  occur  in  the  bronchi  as  well.  Clinically, 
they  are  but  the  extension  of  similar  lesions  in  the  larynx ;  they 
excite  no  characteristic  symptoms  and  have  no  clinical  impor- 
tance. 

Of  the  tertiary  tracheal  lesions,  the  majority  occur  in  the 
lower  third  and  extend  into  the  bronchi.  A  certain  minority 
occur  at  the  upper  third  in  connection  with  laryngeal  disease, 
and  but  one  or  two  instances  of  tertiary  ulceration  of  the  mid- 
dle third  (Mackenzie)  have  been  noted. 

These  tertiary  lesions  are  almost  always  diffuse  infiltrations 
in  and  about  the  trachea  with  surface  ulceration  irregular  in 
extent  and  depth.  Individual  cases  of  circumscribed  tracheal 
gumma  (Hanzel)  and  of  diffuse,  non-ulcerated,  tracheal 
gumma  (Raymond)  have  been  recorded. 

Diffuse,  Ulcerated  Syphiloma. — This,  the  type  lesion 
of  tracheo-bronchial  syphilis,  occurs  almost  exclusively  in  old, 
neglected  cases  of  syphilis.  The  infiltration  involves  the  whole 
wall  of  the  canal,  and  is  often  very  extensive.  The  ulcerations 
are  usually  multiple,  circinate,  and  sharp-edged,  like  syphilitic 
ulcers  elsewhere. 

The  lesion  progresses  slowly,  and  the  ulceration  may  re- 
main superficial  for  many  months.  The  results  of  neglected 
ulcer,  however,  are  (i)  necrosis  of  the  cartilages,  (2)  second- 
ary infection  of  the  deep  structures  of  the  neck,  and  (3)  exten- 
sion of  the  syphilitic  process  to  the  adjacent  lymph  nodes 
(syphilitic  peribronchial  adenitis),  a  very  rare  process,  caus- 
ing pressure  either  upon  the  bronchi  themselves,  or  upon  the 
great  vessels,  or  the  recurrent  laryngeal  nerves. 

Treatment. — Mixed  treatment  must  be  vigorously  admin- 
istered. For  the  low  lesions  no  local  treatment  is  possible; 
for  the  high  ones  tracheotomy,  and  perhaps  intubation  with 
a  specially  long  tube  (Hurd  ^)  may  be  required. 

'  The  Laryngoscope,  1905,  February. 


462  SYPHILIS    OF    THE    AIR    PASSAGES 

Pulmonary  Lesions. — So  rare  and  obscure  is  pulmonary 
syphilis  that  its  very  existence  was  doubted  a  generation  ago. 
Since  then  congenital  syphilis  of  the  lung  has  been  well  defined, 
thanks  chiefly  to  the  work  of  Virchow,  Cornil,  Balzer  and 
Grandhomme/  and  Kokawa.^  But  the  pulmonary  lesions  of 
acquired  syphilis  are  so  rare,  simulate  so  closely  those  of  tuber- 
culosis, and  occur  usually  at  so  late  a  date  in  the  disease  that 
their  very  existence  has  only  recently  been  assured,  and  it  is 
still  far  from  clear  how  frequent  they  are  or  what  may  be  the 
predominant  clinical  or  pathological  type  of  the  disease. 

The  following  summary  of  the  lesions  of  pulmonary  syphi- 
lis, hereditary  and  acquired,  is  founded  chiefly  upon  the  con- 
tributions of  Beriel  ^  and  Milian.^ 

The  essential  lesion  of  pulmonary  syphilis  is  an  interstitial 
pneumonia,  probably  always  beginning  as  a  perivascular,  exu- 
dative process.  This  process  usually  terminates  in  sclerosis, 
rarely  in  the  formation  of  gumma.  It  is  liable  to  the  compli- 
cations of  mixed  infection,  and  often  produces  dilatation  of  the 
bronchi.  Indeed,  Tripier  and  Beriel  contend  that  most  cases 
of  bronchiectasis  are  due  to  unsuspected  previous  pulmonary 
syphilis. 

Syphilitic  Pneumonia. — The  interstitial  pneumonia 
caused  by  syphilis  is  seen  as  an  uncomplicated  process  almost 
exclusively  in  cases  of  hereditary  syphilis.  This  is  the  white 
pneumonia  of  the  newborn,  the  first  description  of  which  is 
commonly  attributed  to  Virchow. 

The  striking  characteristics  of  this  condition  are  thus  de- 
scribed by  that  author : 

*  Rev.  mens.  d.  mal.  de  I'enjance,  1886,  November,  p.  485. 

^  Arch.  j.  Derm.  u.  Syph.,  1906,  vol.  Ixxviii,  pp.  69  and  319.  Many  other 
names  might  be  mentioned  but  the  two  contributions  referred  to  contain  all 
that  is  material. 

-I  "  Syphilis  des  poumons,"  Paris,  1907. 

*  In  Fournier's  "  Traite  de  la  syphilis,"  1906,  vol.  ii.  Part  II,  p.  710. 


SYPHILIS    OF   TRACHEA,    BRONCHI,   AND    LUNGS      463 

"  The  lungs  appeared  so  distended  and  light  that  the  ex- 
aminers believed  they  had  to  do  with  lungs  that  had  already 
breathed.  But  what  was  their  astonishment  to  find  that  frag- 
ments of  this  tissue  sank  in  water.  A  more  attentive  examina- 
tion showed  that,  in  reality,  there  was  not  a  bubble  of  air  in 
the  lungs ;  on  the  contrary,  the  cut  section  had  rather  the  aspect 
of  a  pneumonia  in  the  condition  of  white  hepatization.  Yet  it 
was  possible  to  insufflate  the  lungs." 

Beriel  recognizes  three  histological  types  of  this  pneumonia. 

In  the  adenomatous  type  "  the  lesions  are  essentially  a  con- 
siderable thickening  of  the  stroma  and  a  peculiar  condition  of 


p.t 


Fig.  60.— Hereditary  Syphilis  of  the  Lung:  Area  of  White  Pneumonia. 
N,  nodule  of  interstitial  pneumonia,  n.  a,  adenomatous  neoformation. 
a,  periarteritis,  p.  i,  lesser  degree  of  interstitial  pneumonia  surrounding  the 
nodules,  with  here  and  there  a  dilated  alveolus,     p,  pleura.    (Beriel.) 


the  epithelium,  the  cells  of  which  become  more  or  less  cuboidal, 
so  that  the  tissue  presents  a  striking,  adenomatous  appearance. 
...  It  is  rich  in  vessels  and  generally  infiltrated  with  many 
cells.  ...  In  the  alveoli  are  found  a  greater  or  less  number  of 
exudated  cells.  .  .  .  The  bronchi  show  the  same  infiltration, 
but  are  little  affected,  and  their  epithelium  is  intact.     The  ves- 


464  SYPHILIS    OF    THE    AIR    PASSAGES 

sels  may  show  a  slight  degree  of  endarteritis,  but  there  is 
always  a  great  thickening  of  the  adventitia  "   (Fig.  60). 

The  second,  or  desquamative,  type  is  that  described  by 
Virchow.  The  desquamation  of  cells  into  the  alveoli  is  marked ; 
the  infiltration  of  the  stroma  is  slight. 

The  third,  or  interstitial  pneumonia,  type  shows  consider- 
able interstitial,  subpleural,  peribronchial  and  perivascular  in- 
filtration. There  is  here  also  a  considerable  desquamation. 
There  is  not  the  peculiar  epithelial  change  seen  in  the  adeno- 
matous type. 

These  three  types  are  habitually  more  or  less  intermingled 
in  a  given  case,  and  are  diffused  over  large  areas  if  the  patient 
is  stillborn.  If  the  infant  has  breathed  the  hepatization  is 
lobular.  Comparable  lesions  are  met  with  in  the  adult,  but 
only  in  small,  irregular  areas,  and  the  typical  picture  of 
white,  syphilitic  pneumonia  is  exclusively  seen  in  the  fetus 
or  infant. 

Cicatricial  Lesions. — Syphilitic  sclerosis  of  the  lung  is 
spoken  of  as  "  soft  "  sclerosis  or  "  hard  "  sclerosis,  depending 
upon  the  density  of  the  lesions,  which  density  is,  generally 
speaking,  dependent  upon  the  age  of  the  process  and  the  trans- 
formation of  the  exudate  into  organized  fibrous  tissue.  This 
sclerosis  is  the  common  pulmonary  lesion  of  acquired  syphilis. 
It  is  usually  irregular  in  distribution,  and  is  believed  to  be  more 
common  in  the  lower  than  in  the  upper  lobe,  in  the  right  than 
in  the  left  lung. 

Syphilitic  sclerosis  has  no  very  peculiar  characteristics. 
The  tissue  is  hard,  grayish  white,  or  blackish,  and  very  re^ 
tractile.  It  may  appear  in  radiating  bands  from  a  given  central 
point  or  in  nodular  masses,  often  beneath  the  pleura ;  or,  again, 
there  may  be  a  fibrous  peribronchitis ;  but  this  condition  is  sec- 
ondary to  infiltration  of  the  bronchi,  and  is  only  accidentally, 
as  it  were,  a  pulmonary  lesion. 

Microscopic  examination  of  this  tissue  shows  no  peculiar- 


SYPHILIS    OF    TRACHEA,    BRONCHI,    AND    LUNGS      465 

ity,  unless  it  be  at  its  edges  certain  newly  formed  alveoli  with 
cuboidal  epithelium.  These  are  considered  by  Tripier  and 
Beriel  as  almost  pathognomonic  of  syphilis. 

Bronchiectasis. — Associated  with  the  interstitial  syphi- 
litic changes  in  the  adult  lung,  just  described,  one  almost  always 
finds  bronchial  dilatation  of  various  shapes  and  sizes.  In  many 
instances  the  bronchiectasis  is  so  marked  as  to  be  the  chief 
lesion  and  produces  cavities  of  considerable  size,  the  presence 
of  which  can  be  determined  during  life.  On  section  these  cav- 
ities are  often  found  full  of  pus,  and  may  even  be  gangrenous ; 
they  therefore  appear  to  be  necrotic  in  type  and  similar  to  the 
cavities  caused  by  tuberculosis.  But  histological  examination 
shows  an  epithelial  lining  at  least  in  some  parts  of  the  cavity; 
whence  Tripier  and  Beriel  infer  that  the  cavities  found  in  the 
syphilitic  lung  are  always  bronchiectatic,  and  ascribe  them  to 
the  adenomatous  tendency  of  syphilitic  pneumonia  already 
described. 

Complications. — Rupture  of  a  gumma  into  a  bronchus  is 
one  of  the  classical  features  of  pulmonary  syphilis.  But,  al- 
though many  cases  of  ulcerated  or  gangrenous  bronchiectasis 
provoke  a  foul  or  putrid  expectoration,  the  case  reported  by 
Jacquin  is  probably  the  only  proven  instance  of  ruptured 
gumma  on  record. 

Acute  processes  due  to  mixed  infection,  and  showing  them- 
selves as  intercurrent  bronchitis,  or  broncho-pneumonia,  or 
inflammation  or  gangrene  in  a  bronchiectatic  cavity,  are,  on 
the  other  hand,  important  features  of  pulmonary  syphilis. 

Mixed  infection  by  tuberculosis  is  alleged  to  be  frequent; 
but  so  many  of.  the  classical  cases  of  syphilis  of  the  lung  are 
manifestly  nothing  other  than  irregular  tuberculosis,  that  the 
frequency  with  which  the  two  diseases  occur  together  has  prob- 
ably been  overestimated.  There  is  no  reason  why  the  syphi- 
litic lung  should  not  become  tuberculous,  however,  and  a  few 
authentic  instances  of  this  mixed  infection  are  recorded. 


466  SYPHILIS   OF   THE   AIR   PASSAGES 

Symptoms  of  Tracheo-Bronchial  Syphilis. — Although 
some  authors  recognize  an  acute  secondary  bronchitis,  this  has 
no  other  characteristics  than  that  of  occurring  in  the  first  year 
of  the  disease  and  disappearing  after  mercurial  treatment. 
Such  a  condition  is  possible,  though  perhaps  some  of  the  re- 
corded instances  are  coincidences. 

The  chief  symptom  of  tracheo-bronchial  ulceration  is  in- 
spiratory dyspnea  due  to  the  contraction  of  the  infiltrated  air 
passages.  Gehrhardt  (Milian)  states  that  dyspnea  due  to  lar- 
yngeal obstruction  causes  the  patient  to  throw  back  his  head 
in  the  effort  of  breathing,  while  tracheal  stenosis  makes  him 
throw  it  forward  so  as  to  relax  the  trachea. 

Accompanying  this  dyspnea  there  is  more  or  less  cough  and 
expectoration  and  the  breath  is  more  or  less  foul,  depending 
upon  the  depth  and  extent  of  ulceration.  Such  fatal  complica- 
tions as  edema  of  the  glottis,  inspiration  pneumonia,  and 
asphyxia  by  occlusion  of  one  or  both  bronchi  are  exceptional. 
Infiltration  of  the  surrounding  tissues  may  cause  cellulitis  of 
the  deep  tissues  of  the  neck  as  well  as  involvement  of  the  nerves 
and  vascular  structures.  Such  complications,  however,  are 
extremely  rare. 

Symptoms  of  Hereditary  Pulmonary  Syphilis. — Usually 
there  are  no  symptoms.  The  patient  is  either  stillborn, 
or  dies  within  a  few  hours,  and  a  white  pneumonia  is  dis- 
covered among  other  visceral  lesions  after  death.  Gummata 
are  extremely  rare  (Kokawa).  If  the  infant  lives  a 
few  days  or  weeks  it  is  likely  to  die  of  acute  broncho-pneu- 
monia. 

It  is  to  be  noted  that  the  consolidation  of  syphilitic  pneu- 
monia is  not  very  dense,  and,  although  post-mortem  examina- 
tion may  show  consolidation  throughout  one  or  several  lobes, 
ante-mortem  examination  usually  fails  to  reveal  any  physical 
sign  of  it. 

The  diagnosis  is  founded  upon  the  presence  of  other  lesions 


SYPHILIS   OF   TRACHEA,    BRONCHI,   AND    LUNGS      467 

of  syphilis  and  the  presence  of  dyspnea  and  cyanosis  without 
physical  signs. 

Symptoms  of  Pulmonary  Syphilis  in  the  Adult. — The 
symptoms  of  pulmonary  syphilis  in  the  adult  are  both  obscure 
and  irregular.  There  may  be  marked  symptoms  with  slight 
pathological  change,  and  practically  no  symptoms  with  exten- 
sive lesions.  Thus  the  condition  is  very  rarely  diagnosed  dur- 
ing life.  It  is  usually  associated  with  other  visceral  lesions  of 
syphilis.  It  occurs  late  in  the  disease.  Its  symptoms  may  be 
overshadowed  by  those  of  tertiary  laryngeal  or  tracheo-bron- 
chial  ulceration. 

The  usual  clinical  types  are  the  silent  type,  in  which  the 
lesions  (often  gummatous)  exist  for  years  without  causing 
any  symptoms.  As  Bazin  says :  "  The  victims  of  pulmonary 
syphilis  eat  their  food  and  walk  about  like  people  in  good 
health ;  their  expectoration  is  slight  and  grayish,  their  cough 
and  dyspnea  not  marked."  But  the  course  of  such  a  lesion  may 
be  interrupted  by  acute  attacks  of  bronchitis  or  broncho-pneu- 
monia which  are  liable  to  become  chronic  and  to  relapse ;  hence 
the  bronchial  or  broncho-pneumonic  type  of  the  disease. 

In  the  third  place  there  are  those  cases  in  which  the  more 
or  less  slight  pulmonary  lesions  are  overshadowed  by  the  dysp- 
nea due  to  lesions  in  the  upper  air  passages :  the  tracheal  type. 

Finally,  there  is  the  important  pseudo-tubercular  type  due 
to  interstitial  pneumonia  and  bronchiectasis.  The  course  of 
such  lesions  is  chronic  and  interrupted  by  attacks  of  bronchitis 
or  broncho-pneumonia.  The  symptoms  are  not  very  charac- 
teristic, though  the  dyspnea  may  be  more  marked  than  is  ac- 
counted for  by  the  physical  signs.  The  lesions  are  usually 
seated  in  the  lozver  lobe  and  on  the  right  side.  Pain,  cough, 
expectoration,  and  cyanosis  are  quite  variable.  Hemoptasis 
is  not  common,  though  it  does  occur  and  may  be  repeated  and- 
severe.     The  physical  signs  are  either  those  of  an  irregular 

pneumonia  or  of  the  bronchio-ectatic  cavities.     Pleural  adhe- 
32 


468  SYPHILIS   OF   THE   AIR   PASSAGES 

sions  and  acute  mixed  infection  may  complicate  the  physical 
signs.  Fever  is  absent  and  the  pulse  is  slow  except  during  these 
acute  intercurrent  attacks. 

Diagnosis. — The  diagnosis  of  hereditary  lung  syphilis  is 
made  on  autopsy ;  that  of  trachio-bronchial  ulceration  depends 
upon  the  association  of  dyspnea  and  expectoration  with  other 
evidences  of  ancient  syphilis ;  that  of  pulmonary  syphilis  in  the 
adult  depends  upon  evidences  of  pulmonary  disease  in  connec- 
tion with  old  and  neglected  syphilis;  it  is  usually  associated 
with  syphilis  of  the  liver. 

Differential  Diagnosis. — One  must  distinguish  pulmonary 
syphilis  from  tuberculosis. 

The  lesions  found  by  physical  examination  may  resemble 
tuberculosis,  but  should  be  distinguished  from  it  by  the  evi- 
dences of  syphilis  elsewhere,  the  absence  of  tubercular  bacilli 
from  the  sputum,  the  site  of  the  lesions — which  are  usually 
unilateral  and  seated  in  the  lower  rather  than  in  the  upper 
part  of  the  lung  and  almost  always  on  the  right  side,  the  rela- 
tively slow  pulse  and  slight  fever. 

Two  other  striking  features  may  help  in  the  diagnosis : 
viz.,  marked  dyspnea  with  no  pulmonary  lesion  adequate  to 
account  for  it,  or  marked  pulmonary  lesions  of  great  chronicity 
with  relatively  slight  fever  or  impairment  of  the  patient's  health. 

Finally,  the  therapeutic  test  helps  to  clear  up  the  diagnosis, 
though  its  findings  are  not  absolute,  and  an  ancient  sclerosis 
or  bronchiectasis  cannot  be  affected  by  specific  treatment. 

Treatment. — The  treatment  for  all  these  tertiary  lesions  in 
the  adult  should  be  "  mixed."  But,  on  account  of  the  bronchial 
or  laryngeal  congestion  which  may  result  from  the  adminis- 
tration of  iodids,  these  must  be  given  with  extreme  caution,  if 
at  all ;  and  the  best  rule  is  to  submit  the  patient  to  a  course  of 
intramuscular  mercurial  injections  before  administering  the 
iodid.  If  these  fail,  iodids  may  be  given,  but  only  in  small 
doses,  very  gradually  increased. 


CHAPTER    XXXI 

SYPHILIS  OF   THE  LIVER 

The  preeruptive  jaundice  due  to  secondary  liver  syphilis 
has  already  been  described  (page  265).  Exceptionally,  this 
jaundice  occurs  or  relapses  at  a  later  period  ^  (within  the  first 
eighteen  months).  Although  usually  mild,  a  few  fatal  cases 
have  been  recorded.^ 

But  the  term  "  liver  syphilis  "  is  broadly  applied,  not  to 
this  transient  secondary  lesion,  but  to  the  tertiary,  the  sclero- 
gummatous  lesions,  which  are  the  commonest  and  most  obvious 
visceral  manifestations  of  syphilis. 

Occurrence. — Tertiary  syphilis  of  the  liver  occurs  in  the 
later  years  of  the  disease.  It  is  often  not  diagnosed  during  life ; 
hence  one  cannot  keep  an  accurate  clinical  record  of  its  fre- 
quency. I  have  record  of  only  7  cases,  occurring  respectively 
at  three,  five,  six,  fifteen,  sixteen  (relapse  at  twenty-two), 
twenty,  and  thirty  years  after  the  chancre.  Fournier  found 
liver  syphilis  only  9  times  among  4,400  tertiary  lesions. 

Alcohol,  hardship,  and  neglect  are  obvious  etiological  fac- 
tors. Hudelo  states  that  25  cases  are  seen  in  men  to  10  in 
women. 

Pathology.  — The  pathological  changes  wrought  by  syphilis 
upon  the  liver  are  almost  precisely  the  same  as  those  of  the 
lung,  but  uncomplicated  by  the  secondary  infections  and  ade- 
nomatous chancres  that  confuse  the  latter  lesion. 


*  Only  once  noted  in  my  series. 
'  Acute  parenchymatous  hepatitis. 

469 


470 


SYPHILIS    OF   THE   LIVER 


Hereditary  Syphilis. — Syphilitic  stillborn  infants  always 
show  liver  lesions  (Hochsinger).  Those  that  live  usually 
escape. 

The  liver  is  increased  in  size,  pale  in  color,  but  may  show 
no  other  macroscopic  change.  Numerous  small  (miliary)  gum- 
mata  are  sometimes  found. 

Microscopic  examination  reveals  a  characteristic,  diffuse, 
perivascular,  small-cell  infiltration.  The  miliary  gummata 
merely  show  a  localized  intensification  of  this  process. 

Hecker  has  described  an  acute  necrosis  without  infiltra- 
tion, and  Schiippel  an  hereditary  pyelophlebitis. 

Secondary  (Acquired)  Syphilis. — The  lesions  are  those 
of  an  acute,  diffuse,  congestive,  or  degenerative  toxic  hepatitis 
with  but  little  perivascular  exudation. 

Tertiary  (Acquired  ^)  Syphilis. — Although  it  is  cus- 
tomary and  convenient  to  describe  hepatic  sclerosis  and  hepatic 
gumma  as  though  these  lesions  often  stood  alone,  and  although 
actual  instances  of  hepatic  gumma  without  sclerosis  or  of  syph- 
ilitic sclerosis  without  gumma  have  been  reported,  the  fact 
remains  that  gumma  and  sclerosis  are  but  manifestations  of  a 
single  pathologic  process,  and  almost  always  occur  together. 
The  clinical  picture  varies  with  the  predominance  of  the  one 
or  the  other,  but  the  pathologic  picture  remains  essentially 
the  same. 

The  Gross  Aspect. — The  liver  is  usually  large  and  de- 
formed. It  may  or  may  not  be  adherent  to  the  surrounding 
organs;  but  the  capsule  almost  always  shows  more  or  less 
irregular  whitish  thickening.  This  thickening  may  be  due  to 
a  diffuse  productive  perihepatitis  or  to  the  thick  scars  left  by 
healed  gummata. 

The  irregular  shape  of  the  liver  is  due  to  bands  of  dense 
sclerotic  tissue  traversing  it  irregularly,  criss-crossing  at  vari- 

*  This  type  may  occur  in  the  later  years  of  an  inherited  syphilis.     It  is 
well  described  by  Funke,  Med.  News,  1905,  vol.  Ixxxvii,  p.  67. 


SYPHILIS   OF   THE    LIVER  471 

ous  points,  radiating  from  certain  others,  and  generally  most 
numerous  near  the  anterior  surface  of  the  liver  in  the  region 
about  the  falciform  ligament.  The  quantity  and  distribution 
of  this  sclerotic  tissue  is  utterly  irregular,  and  it  is  quite  futile 
to  attempt  to  classify  the  resultant  deformity  in  any  but  the 
broadest  terms :  as  a  rule,  the  process  is  most  marked  near  the 
anterior  surface  of  the  right  lobe,  whence  the  intersecting 
fibrous  bands  radiate  in  every  direction,  thinning  out  as  they 
approach  the  hilum.  This  produces  a  generally  lobulated 
appearance. 

The  gummata  (cf.  also  p.  328)  are  found  either  as  hard, 
yellowish  nodules  or  as  cheesy  masses  at  the  intersection  of 
several  bands  of  sclerosis  or  beneath  (and  involving)  the  cap- 
sule (Fig.  61),  These  gummata  are  rarely  smaller  than  a  pea, 
and  may  attain  an  enormous  size,  projecting  noticeably  from 
the  surface  of  the  enlarged  viscus.  They  are  usually  quite 
numerous. 

If  this  sclera- gummatous  process  is  slight  and  healed,  a 
few  stellate  scars  on  the  capsule,  whence  some  slight  fibrous 
bands  radiate  within  the  organ,  may  be  all  the  evidence  remain- 
ing, while  if  pronounced  it  may  result  in  marked  atrophy  of 
the  affected  lobe. 

Such  exceptional  conditions  as  diffuse,  general  hypertrophy, 
generalized  sclerotic  atrophy,  and  miliary  gummata  (such  as 
occur  often  in  the  hereditary  type)   need  only  be  mentioned. 

Microscopical  Characteristics. — The  cirrhosis  is  seen  to  be 
chiefly  perilobular,  though  it  sends  into  the  lobules  irregular, 
blunt  bands  of  fibrous  tissue.  Here  and  there  at  the  edges 
of  the  sclerotic  bands  are  areas  of  more  recent  syphiloma, 
the  usual  perivascular  cellular  exudate  in  process  of  organiza- 
tion into  fibrous  tissue.  Exceptionally,  this  exudate  is  massed 
into  minute  "  miliary  gummata,"  while,  chiefly  at  centers  of 
fibrous  intersection,  the  large  gummata  are  seen  in  various 
stages  of  degeneration  (Fig.  61). 


472 


SYPHILIS    OF    THE    LIVER 


There  is  considerable  infiltration  of  the  hepatic  artery  and 
its  branches,  and  of  the  portal  system  as  well. 


Fig.  6i. — Gxjmma  of  Liver.     (Councilman,  in  "Morrow's  System.") 

Associated  Lesions. — Suppuration  of  a  liver  g-umma  is  ex- 
tremely rare.  Amyloid  degeneration  due  to  syphilis  presents 
no  peculiar  characteristics  (page  270)  ;  it  occurs  alone  or  in 
connection  with  sclero-gummatous  hepatitis.  Adhesion  of  the 
liver  to  the  surrounding  viscera  is  fairly  common.  Obstruc- 
tion of  the  larger  vessels  or  bile  ducts  by  gumma  or  sclerosis 
is  exceptional. 

The  liver  lesions  are  usually  associated  with  enlargement 


SYPHILIS    OF    THE    LIVER 


473 


of  the  spleen  and  chronic,  interstitial  nephritis.  Other  tertiary 
lesions  (of  skin,  bones,  etc.)  are  often  to  be  found. 

Symptoms. — The  symptoms  of  hepatic  syphilis — when  it 
excites  symptoms — are  usually  comparable  to  those  of  (non- 
syphilitic)  cirrhosis  or  of  neoplasm.  In  many  instances,  how- 
ever, there  are  no  local  signs  of  disease,  in  which  case  there 
may  or  may  not  be  a  marked  and  progressive  cachexia.  Final- 
ly, there  remains  a  small  class  of  cases  in  which  fever  is  the 
predominant  symptom. 

We  may,  therefore,  classify  the  symptoms  of  hepatic  syphi- 
lis according  to  the  following  types,  arranged  in  what  is  prob- 
ably their  order  of  frequency;  but  recognizing  that,  whether 
in  the  liver  or  elsewhere,  syphilis  is  bound  by  no  absolute  law 

•^  I.  Neoplastic  type. 

2.  Cirrhotic  type. 

3.  Cachectic  type. 

4.  Febrile  type. 

5.  Silent  type. 

Neoplastic  Type. — The  first  symptom  noted  by  the  patient 
is  usually  pain  or  ascites,  less  often  jaundice. 

The  pain  often  amounts  to  little  more  than  an  uneasiness 
in  the  region  of  the  liver  with  slight  tenderness.  This  pain 
is  increased  by  exercise.  It  increases  gradually  during  the  first 
few  months  of  the  disease,  but  rarely  attains  any  great  inten- 
sity. Nocturnal  exacerbation,  so  common  with  other  types  of 
syphilitic  pain,  is  rather  the  exception  here.  After  lasting  a 
few  months,  the  pain  usually  lessens  little  by  little,  and  finally 
disappears. 

This  pain  is  ascribed  to  perihepatitis.  In  those  exceptional 
instances  in  which  the  liver  becomes  adherent  to  the  adjacent 
viscera  the  pain  may  be  intense. 

Ascites  is  a  frequent  symptom  of  syphilis  of  the  liver. 
It  increases  slowly  and  recurs  rapidly  after  paracentesis. 


474 


SYPHILIS    OF    THE    LIVER 


Jaundice  is  a  rather  rare  symptom.  When  present  it  entails 
all  the  associated  symptoms,  such  as  clay-colored  stools,  bile- 
stained  urine,  itchy  skin,  etc. 

Later  in  the  disease  such  symptoms  as  progressive  cachexia 
(loss  of  flesh  and  strength),  gastro-intestinal  derangements 
(loss  of  appetite,  vomiting,  intestinal  fermentation,  diarrhea), 
and  various  secondary  results  of  impeded  portal  circidation 
(such  as  hemorrhoids,  varicosities,  edema)  occur,  as  in  other 
chronic  hepatic  diseases.  The  syphilis  imprints  upon  them  no 
special  features,  and  they  have  no  diagnostic  significance. 

Physical  examination  usually  reveals  a  large  liver,  which 
may  reach  almost  to  the  umbilicus.  Upon  the  surface  of  the 
organ  one  may  often  feel  one  or  more  large,  rounded  projec- 
tions, while  similar  projections  from  its  free  border  may  ren- 
der this  utterly  irregular.  These  projections  may  even  be 
pedunculated  and  movable.  Moreover,  a  careful  examination 
usually  shows  that  one  lobe  or  one  part  of  a  lobe  is  dispropor- 
tionately enlarged. 

The  spleen  is  usually  enlarged,  and  the  kidneys  the  seat  of 
chronic  nephritis. 

Diagnosis. — In  certain  cases  the  diagnosis  is  easy,  either 
from  the  syphilitic  history  or  the  contrast  between  the  large 
or  multiple  neoplasms  manifestly  growing  from  the  surface 
of  the  liver  with  the  excellent  health  of  the  patient.  But  often 
— exceedingly  often  in  current  surgical  experience — syphilis  is 
absolutely  denied,  and  local  conditions  are  so  obscure  as  to  per- 
mit grave  doubt.  If  the  tumor  manifestly  arises  from  the  liver, 
it  may  be  presumed  to  be  syphilitic,  for  primary  neoplasm  of 
the  liver  is  extremely  rare;  but  if  it  is  in  the  region  of  the  gall- 
bladder, the  probability  is  against  syphilis  and  in  favor  of  neo- 
plasm, inflammation  about  the  biliary  passages,  or  tubercular 
peritonitis.    Yet  the  following  case,  related  by  Cumston,^  is  an 

^  Ann.  Surg.,  1903,  vol.  xxxii,  p.  725. 


SYPHILIS    OF    THE    LIVER  475 

excellent  example  of  how  every  means  of  reaching  a  diagnosis 
— even  exploratory  operation — may  fail : 

Case  XXXV. — Male,  about  forty  years  old.  For  several 
months  he  suffered  pain  in  the  right  hypochondrium,  and  has 
been  slightly  jaundiced.  Tongue  furred;  temperature •  normal ; 
pulse  80.  "  A  large,  somewhat  nodulated  mass  in  the  region  of 
the  gall-bladder;  the  border  of  the  liver  extending  about  three 
fingers'  breadth  below  the  costal  margin." 

Diagnosis,  tumor  of  liver  or  biliary  passages. 

Laparotomy  revealed  slight  ascites,  a  large  liver,  and  a  gall- 
bladder surrounded  by  adhesions,  but  which  when  freed  proved 
normal  and  empty.  A  diagnosis  of  ulcer  of  the  duodenum  was 
therefore  made,  but  the  adhesions  were  so  dense  it  was  deemed 
inadvisable  to  interfere  further. 

After  operation  it  was  learned  that  the  patient  had  had 
syphilis,  and  he  was  therefore  treated  by  large  doses  of  potas- 
sium iodid.     Cure  in  three  months,  persisting  two  years. 

In  the  same  paper  Dr.  Cumston  reports  a  number  of  in- 
stances in  which  he  resorted  to  exploratory  incision  for  a  diag- 
.  nosis.  Such  a  measure  is  entirely  proper  if  the  condition  ap- 
pears to  be  operable  (supposing  it  to  be  malignant),  and  not 
primary  in  the  liver;  but,  if  inoperable  or  apparently  growing 
from  the  liver,  a  sharp  test  course  of  antisyphilitic  medica- 
tion should  be  given  the  preference. 

Cirrhotic  Type. — Less  frequently  the  disease  shows  all 
the  symptoms  narrated  in  the  preceding  paragraph,  except  that 
there  are  no  marked  irregularities  or  tumors  palpable  upon  the 
surface  of  the  liver.  Accordingly,  the  condition  resembles  non- 
syphilitic  cirrhosis.  The  liver  is  usually  moderately  enlarged 
(or  it  may  be  contracted),  and  thus  the  condition  simulates  the 
hypertrophic  (or  the  atrophic)   form. 

Diagnosis. — The  presence  of  other  syphilitic  lesions,  scars, 
or  a  syphilitic  history  are  almost  essentially  for  a  differential 
diagnosis.  The  diagnosis  by  exclusion  w'ould  not  be  unjustifi- 
able if  a  case  of  cirrhosis  not  manifestly  due  to  alcoholism  or 


476  SYPHILIS   OF   THE    LIVER 

any  other  of  the  usual  causes  were  subjected  to  mixed  treat- 
ment, and  cured  thereby. 

Cachectic  Type. — Not  only  may  the  characteristic  irreg- 
ularities of  tumors  upon  the  liver  be  lacking,  but  there  may 
be  also  an  entire  absence  of  jaundice  or  ascites,  of  pain,  and 
of  marked  change  in  the  size  of  the  liver.  The  patient  suffers 
vague  intestinal  symptoms,  and  becomes  gradually  more  and 
more  cachectic  without  obvious  cause.  Very  careful  examina- 
tion may  disclose  a  slight  enlargement  of  the  liver  and  spleen, 
but  even  then  there  may  be  no  direct  evidence  of  hepatic  disease. 
Such  cases  are  habitually  undiagnosed  unless  submitted  to  ex- 
ploratory operation  or  until  they  reach  the  autopsy  table,  unless 
the  presence  of  other  lesions  of  syphilis  shall  lead  to  a  course 
of  mixed  treatment. 

Febrile  Type. — The  so-called  fever  of  tertiary  syphilis 
has  already  been  described  (page  269).  In  most  of  the  re- 
ported instances  this  fever  accompanies  syphilis  of  the  liver, 
and  where  manifest  lesions  of  the  liver  were  absent  one  may 
doubt  whether  autopsy  might  not  have  revealed  some  lesions 
of  this  organ.  Though  this  fever  is  neither  frequent  nor  char- 
acteristic in  type,  it  is  none  the  less  important,  since  it  is  mani- 
festly due  to  syphilis  and  usually  to  liver  syphilis,  and  may  be 
cured  by  antisyphilitic  treatment. 

Silent  Type. — Post-mortem  examination  reveals  active 
lesions  or  scars  of  hepatic  syphilis  in  many  cases  that  have 
shown  no  symptoms  of  such  lesions  during  life.  The  precise 
frequency  of  such  cases  has  not  been  estimated. 

Diagnosis. — Hudelo  lays  down  these  two  fundamental 
propositions : 

"  I.  Every  obscure  cachectic  condition  in  a  patient  known 
to  be  syphilitic  suggests  a  visceral  lesion,  and  in  particular  a 
lesion  of  the  liver. 

"  2.  Every  chronic  disease  of  the  liver  with  irregular  symp- 
toms and  of  obscure  origin  should  make  us  think  of  syphilis." 


SYPHILIS    OF   THE    LIVER  477 

Prognosis. — The  prognosis  is  bad  in  a  sense,  for  liver 
syphilis  occurs  in  relatively  old  and  obstinate  cases,  and  the 
patient  is  rarely  willing  or  able  to  undergo  the  prolonged 
course  of  treatment  necessary  to  assure  a  cure.  On  the  other 
hand,  it  is  surprising  how  well  the  worst  cases  sometimes 
do  under  treatment,  so  long  as  the  other  viscera — notably  the 
kidneys — are  not  too  gravely  implicated. 

Treatment. — A  strict  diet  and  the  application  of  mercury 
by  some  other  than  the  alimentary  route  are  required  to  spare 
the  digestive  organs;  iodid  must  be  given  freely.  Surgical 
measures,  such  as  those  employed  in  certain  cases  by  Dr.  Cum- 
ston,  for  example,  are  not  calculated  to  cure  the  disease,  and 
but  little  good  can  be  expected  from  them,  unless  by  the  removal 
of  pedunculated  masses  of  gummatous  tissue  ( Koenig  ^  and 
Cumston). 

^  Berl.  klin.  Woch.,  1905,  February  6. 


CHAPTER    XXXII 
SYPHILIS  OF   THE  GENITAL  ORGANS 

SYPHILIS   OF   THE   TESTICLE 

Syphilis  of  the  testicle  is  a  relatively  common  and  char- 
acteristic lesion,  which,  like  the  other  visceral  lesions,  is  much 
more  often  found  on  autopsy  than  during  life. 

I  have  record  of  67  cases,  10  of  them  bilateral.  The  fol- 
lowing table  shows  the  dates  of  onset : 

4  to    7  months 3   cases 

12  to  18       "       5      " 

2  years 4' 

3  "  9^     " 

4  "  6      " 

5  "  I    case 

6  "  4   cases 

7  "      3      " 

8  "      I    case 

g     "      2   cases 

10  "       I    case 

11  "       4   cases 

12  "      3      " 

IS     "      2^     " 

26     "      I    case 

31     "       -'     " 

Indefinite 17^  cases 

It  will  be  noted  that,  though  three  of  the  cases  occurred 
between  the  fourth  and  the  seventh  month,  the  lesion  is  not 
common  during  the  first  year;  though  over  half  the  cases 
occurred  within  the  first  four  years. 

«  One  bilateral.  ^  Three  bilateral.  ^  Six  bilateral. 

478      • 


SYPHILIS    OF   THE   TESTICLE  479 

Yet  the  appearance  of  syphilis  in  both  testicles  is  no  evi- 
dence of  a  recent  syphilis,  as  shown  by  its  occurrence  once 
in  the  fifteenth  and  once  in  the  thirty-first  year. 

Morbid  Anatomy. — The  French  school,  following  Dron,^ 
recognize  a  secondary  epididymitis  and  a  tertiary  orchitis  or 
epididymo-orchitis.  The  distinction  cannot  be  clinically  estab- 
lished. Of  my  three  earliest  cases  one  was  distinctly  an 
orchitis,  and  other  authors  (cf.  Lang)  have  reported  similar 
experiences. 

Clinically  it  is  safer  to  consider  all  syphilis  of  the  testicle 
rather  tertiary  than  secondary. 

Tlic  Testicle. — The  syphilitic  testicle  usually  shows  marked 
interstitial  sclerosis,  sometimes  considerable  gummatous  infil- 
tration. Thus  the  process  is  the  familiar  sclero-gtunmatous 
one ;  but  as  the  inflammation  is  painless  and  usually  progresses 
very  slowly,  it  may  never  be  discovered  at  all,  or  it  may  almost 
totally  destroy  the  seminal  tubules  before  the  patient  considers 
it  worthy  of  medical  care. 

Active  gummatous  orchitis,  however,  may  cause  rather 
rapid  enlargement  and  terminate  by  involvement  of  the  over- 
lying tissues  and  eruption  through  the  skin,  leaving  a  typical 
syphilitic  ulcer,  in  the  base  of  which  the  tubular  structure  of 
the  testicle  may  be  discerned. 

The  Epididymis. — The  epididymis  alone  may  be  involved 
(secondary  epididymitis  of  Dron),  though  more  often  the  tes- 
ticle is  implicated  as  well.  The  lesion  is  usually  confined  to 
the  globus  major,  which  forms  a  hard,  solid,  infiltrated  ma'ss 
with  a  sharp  edge.  It  caps  the  end  of  the  testicle,  separated 
from  it  by  a  distinct  sulcus,  so  that  the  organ  seems  to  be 
resting  in  a  clam  shell.  Gummatous  nodules  are  very  rarely 
felt  in  the  epididymis.  This  diffuse  infiltration,  sharp-edged, 
not  nodular  and  not  sensitive,  is  very  characteristic  of  syphilis. 

^  Archiv.  gen.  de  med.,  1863,  vol.  ii,  pp.  513,  724. 


480  SYPHILIS   OF   THE   GENITAL   ORGANS 

The  French  speak  of  it  as  a  "  helmet  crest " ;  the  comparison 
with  a  clam  shell  is  more  famihar  to  our  minds, 

I  have  in  one  instance  seen  syphilis  begin  in  the  epididymis 
as  a  rounded  nodule,  the  size  of  a  marrow-fat  pea,  and  to 
progress  by  the  addition  of  other  nodules  in  the  epididymis 
and  in  the  testicle  itself.  These  gummata  so  closely  resembled 
tubercles  that  the  testicle  was  removed  under  a  mistaken  diag- 
nosis. Such  rounded  nodules  in  the  epididymis,  however,  are 
extremely  rare. 

The  Tunica  Vaginalis. — Hydrocele  is  almost  always  pres- 
ent, but  the  amount  of  fluid  is,  as  a  rule,  not  very  great. 
Adhesive  vaginalitis  is  found  after  the  fluid  has  been  resorbed 
in  the  course  of  a  cure. 

Symptoms. — The  characteristics  of  the  syphilitic  testicle 
are  painlessness  and  slow  growth ;  as  a  rule  but  one  testicle  is 
involved.  It  does  not  attain  a  very  great  size;  it  does  not 
ulcerate  through  the  skin  unless  it  has  been  neglected  for  a 
long  time. 

Examination  reveals  a  testicle  wooden  in  hardness.  If  the 
epididymis  is  involved,  the  sharp,  clam-shell  edge  of  the  globus 
major  (less  often  the  globus  minor)  can  usually  be  made  out 
without  drawing  off  the  hydrocele  fluid. 

If  there  is  orchitis,  the  testicle  is  either  generally  involved, 
evenly  and  densely  hard,  or  else  it  is  of  uneven  hardness,  with 
projecting  small  gummata. 

The  vas  deferens  was  involved  in  only  one  of  my  cases. 
The  general  health  is  not  impaired,  but,  if  both  testicles  are 
involved,  sexual  appetite  and  power  are  likely  to  be  lost. 

The  course  of  the  disease  is  infinitely  slow ;  it  terminates 
either  in  fungus  or  in  atrophy. 

Prognosis. — The  prognosis  is  excellent.  Whatever  part 
of  the  parenchyma  has  not  been  destroyed  by  sclerosis  will 
continue  to  functionate,  and  the  testicle  which  has  been  syphi- 
litic for  years  may  still  secrete  spermatozoa.     But  the  patient 


CHANCRE    REDUX  481 

should  be  warned  that  the  result  of  treatment  upon  an  en- 
larged testicle  may  be  to  cause  such  absorption  of  the  syphi- 
litic tissue  as  to  reduce  the  gland  far  below  its  normal  size, 
while  any  delay  in  instituting  treatment  will  only  make  this 
atrophy  more  marked. 

The  hydrocele  disappears  with  cure  of  the  orchitis. 

Diagnosis. — The  diagnosis  of  syphilitic  testicle  is  often 
easy  from  the  appearance  of  the  organ  and  the  syphilitic  his- 
tory. Exceptionally,  the  onset  of  the  disease  is  accompanied 
by  mixed  infection,  so  that  for  a  time  the  testicle  is  tender 
and  there  is  some  little  temperature. 

This  mixed  infection  is  not  obviously  connected  with 
gonorrhea,  and  usually  leads  to  the  diagnosis  of  tuberculosis ; 
but  in  a  short  time  the  fever  and  tenderness  disappear  and 
the  characteristic  epididymitis  or  orchitis  remains. 

In  the  later  stages  the  general  irregular  involvement  of 
the  whole  gland  may  lead  to  a  diagnosis  of  neoplasm ;  but 
here  the  general  rule  applies  absolutely :  No  testicle  should  be 
removed  for  neoplasm  until  the  patient  has  been  given  the 
benefit  of  a  test  course  of  mixed  treatment,  which  test  course 
should  imply  hypodermic  medication. 

The  aspirating  needle  may  do  good  service,  both  in  with- 
drawing the  hydrocele  that  obscures  the  outlines  of  the  testicle 
and  in  distinguishing  between  a  solid  growth  and  hematocele. 

Treatment. — The  general  treatment  is  along  the  usual 
lines.  We  may  not  expect  to  bring  a  badly  disorganized  tes- 
ticle back  to  an  entirely  normal  condition.  Local  treatment 
is  of  no  value.  The  hydrocele  requires  no  treatment.  Ancient 
syphilis  of  the  testicle  often  resists  every  form  of  treatment 
short  of  mercurial  injections. 

CHANCRE   REDUX 

Any  syphilid,  secondary  or  tertiary — papular,  ulcerative, 
tubercular,  gummatous,  squamous,  mucous — may  occur  upon 


482  SYPHILIS   OF   THE   GENITAL   ORGANS 

the  penis.  In  this  there  is  nothing  extraordinary  or  impor- 
tant. But  the  fact  that  certain  of  these  syphihds  absolutely 
mimic  true  chancre  is  most  important.  Such  sores  are  com- 
mon. They  are  the  foundation  for  many  a  theoretical  "  sec- 
ond attack  "  of  syphilis.  They  have  misled  the  best  of  syph- 
ilologists,  and  will  continue  to  mislead  so  long  as  men  dare 
make  the  diagnosis  of  chancre  from  the  appearance  of  the 
sore  alone;  for  between  true  chancre  and  eroded  or  ulcerated 
syphilitic  tubercle  or  gumma  of  the  penis  it  is  impossible  to 
distinguish  without  collateral  evidence. 

Hence  the  name  and  the  significance  of  cJiancre  redux. 

Chancre  redux  is  thus  nothing  more  than  a  tubercular  or 
gummatous  syphilid  upon  the  glans  penis  or  the  foreskin.  It 
imitates  true  chancre  in  all  its  types;  it  may  or  may  not  be 
phagedenic.  When  it  occurs  in  the  first  two  or  three  years 
of  the  disease  it  usually  springs  from  the  scar  of  the  chancre, 
but  later  it  manifests  no  such  predilection.  It  is  usually  single 
(though  I  have  seen  three  appear  almost  simultaneously  in 
the  twenty-seventh  year  of  the  disease). 

Occurrence. — Our  records  show  75  instances  of  chancre 
redux  in  71  patients.  The  four  relapsing  cases  occurred  in 
the  following  years :  one  to  three,  eleven  to  twenty-seven, 
thirteen  to  seventeen,  and  fourteen  to  twenty-one.  The  date 
of  onset  was  as  follows : 

First  year 3  cases  Tenth  year 3  cases 

Second  year 4     "  Eleventh  to  fourteenth  year.  10 

Third  year 11     "  Sixteenth  to  seventeenth  year  4    " 

Fourth  year 3     "  Twentieth     to     twenty-tirst 

Fifth  year 7     "  year 2    " 

Sixth  year 8     "  Twenty-sixth      to      twenty- 
Seventh  year 8     "  ninth  year 4    " 

Eighth  year i  case  Thirty-second  year i  case 

Ninth  year i     "  Indefinite 5  cases 

Thus  half  the  lesions  appeared  between  the  third  and  the 
seventh  years  of  the  disease. 


CHANCRE    REDUX  483 

Diagnosis. — To  the  description  given  above,  the  diagnos- 
tic table  on  page  246,  and  the  instances  of  erroneous  diagnosis 
on  page  44,  nothing  need  be  added.  We  may  summarize 
by  stating  that  chancre  redux  usually  lasts  much  longer  than 
true  chancre,  is  quite  frequently  phagedenic,  is  not  associated 
with  inguinal  adenitis  except  accidentally,  does  not  reveal  the 
spirocheta  in  smears  taken  from  its  surface,  and  is  not  fol- 
lowed by  any  outbreak  of  secondary  symptoms. 

Treatment. — The  treatment  is  that  of  the  same  lesions 
elsewhere  on  the  body.  The  sore  may  be  kept  clean  by  calomel 
powder. 


33 


CHAPTER    XXXIII 

SYPHILIS    OF    THE    CIRCULATORY    AND    LYMPHATIC 

SYSTEMS 

The  syphilitic  lesions  of  the  capillaries  that  underlie  the 
pathology  of  all  syphilitic  lesions  (page  48)  and  that  disease 
of  the  cerebral  arteries  which  is  the  most  important  feature 
of  syphilis  of  the  nervous  system  (page  373),  have  already 
been  described.  Compared  to  these  two  the  remaining  lesions 
of  the  circulatory  and  lymphatic  systems  are  relatively  infre- 
quent, though  some  of  them  (e.  g.,  syphilis  of  the  aorta)  are 
extremely  grave. 

The  subject  may  be  subdivided  as  follows: 
Syphilis  of  the  heart. 
Secondary  lesions. 
Tertiary  lesions. 

Lesions  of  the  coronary  arteries. 
Syphilis  of  the  aorta. 

Aneurysm. 
Syphilis  of  the  arteries  of  the  extremities. 

Aneurysm. 
Syphilis  of  the  veins. 
Syphilis  of  the  lymphatic  system. 

SYPHILIS    OF    THE    HEART 

Syphilis  of  the  heart  is  both  rare  and  obscure.     The  single 
instance  of  it.  on  our  records  has  been  mentioned   (page  5). 
This  was  supposed  to  be  a  syphihtic  myocarditis ;  it  improved 
484 


TERTIARY   LESIONS  485 

slowly  under  treatment  and  was  finally  cured.  In  all  of  its 
manifestations  syphilis  of  the  heart  simulates  other  conditions, 
from  which  it  can  be  distinguished  only  by  the  therapeutic  test 
or  by  autopsy,  the  former  a  test  unsatisfactory  to  the  pathol- 
ogist, the  latter  a  proof  of  little  avail  for  the  patient. 

Secondary  Lesions 

Fournier  recognizes  three  clinical  types  of  "  secondary  " 
heart  lesions,  manifested  respectively  by  palpitations,  tachy- 
cardia, and  cardiac  arrhythmia.  That  such  conditions  occur  in 
syphilis  cannot  be  doubted,  but  that  they  are  due  to  syphilis 
it  is  almost  impossible  to  prove;  they  do  not  kill,  they  get  well 
under  antisyphilitic  treatment ;  they  also  get  well  without  such 
treatment. 

I  have  recently  seen  two  cases  in  point;  both  developed 
spontaneously,  and  while  under  treatment  a  most  annoying 
tachycardia.  One  case  occurred  in  the  first,  the  other  in  the 
third  year  of  the  disease.  In  both  instances  antisyphilitic 
medication  was  at  once  suspended,  hygienic  and  tonic  meas- 
ures instituted,  and  after  a  few  weeks  the  heart  resumed  its 
normal  action,  and  the  tachycardia  has  not  recurred. 

Doubtless  all  the  cardiac  irregularities  occurring  during 
early  syphilis  are  attributable  to  neurosis  (which  may  itself 
be  caused  by  syphilitic  toxemia)  or  to  digestive  disturbance, 
as  these  were,  and  may  be  cured  by  appropriate  measures  and 
without  the  aid  of  antisyphilitic  remedies.. 

Tertiary  Lesions 

Sclero-gummatous  Myocarditis. —  In  the  heart,  as  in  the 
other  viscera,  diffuse  syphilitic  inflammation  and  localized 
gumma  always  coexist,  though  clinically  one  or  the  other  pre- 
dominates. The  areas  of  sclerosis  (or  interstitial  myocarditis) 
follow  the  sclerosed  capillaries  of  the  coronary  arteries.  The 
gummata  may  be  single  or  multiple,  small  or  large. 


486  SYPHILIS    OF   THE    CIRCULATORY   SYSTEM 

Symptoms. — The  myocarditis  causes  arrhythmia  and  dila- 
tation. Gumma  ^  causes  sudden  heart  faiUire;  it  cannot  be 
diagnosed  during  Hfe. 

Diagnosis. — Symptoms  of  myocarditis  (arrhythmia  and 
dilatation)  in  a  known  syphilitic  demand  a  prompt  "  test " 
course  to  prove  whether  the  myocarditis  is  syphilitic. 

For  gumma  there  is  no  diagnosis. 

Pericarditis  and  Endocarditis. — These  are  post-mortem 
features  of  syphilitic  myocarditis. 

Bradycardia  and  Stokes- Adams  Syndrome.— These  are 
exceptionally  due  to  syphilis.  In  a  recently  reported  case  the 
cause  of  heart  block  was  found  to  be  a  gumma  of  the  bundle 
of  His.- 

Lesions  of  the  Coronary  Arteries 

Syphilitic  lesions  of  the  coronary  arteries,  though  always 
associated  with  similar  lesions  in  the  aorta,  and  often  with 
myocarditis,  may  clinically  dominate  the  scene.  The  arteries 
are  affected  throughout  their  length,  all  the  coats  are  involved 
(endoperiarteritis),  the  inflamed  vessel  rapidly  becomes  scle- 
rosed (Deguy^). 

The  clinical  manifestation  of  syphilis  of  the  coronary  ar- 
teries may  be  sudden  death  due  to  infarct,  rupture  of  the  heart, 
or  aneurysm  of  the  artery  itself;  but,  as  a  rule,  the  symptom 
complex  is  that  of  angina  pectoris. 

Syphilitic  Angina  Pectoris. — "  Syphilitic  coronaritis  with 
angina  pectoris  in  persons  thirty  or  thirty-five  years  of  age 
(Henderson)  ;  it  is  as  frequent  in  women  as  in  men  (Fraenkel) 
— it  usually  ends  in  sudden  death — and  antisyphilitic  treatment 
is  all-powerful  ■*  if  the  diagnosis  is  made  in  time  "  (Deny). 

*  Bruhns,  Berl.  klin.  Wochenschr.,  1906,  vol.  xliii,  p.  513. 
^Presse  med.,  1907,  xv,  No.  8. 

^  Fournier's  Traite,  vol.  ii,  Part  II,  p.  773.     An  excellent  essay  on  cardiac 
syphilis. 

^  Cf.  Dieulafoy,  Presse  med.,  vol.  xiv,  No.  32. 


SYPHILIS   OF   THE   AORTA  487 

SYPHILIS    OF    THE    AORTA 

Syphilis  of  the  aorta  is  confined  ahnost  exchisively  to  the 
arch,  where  it  produces  patches  of  endoperiarteritis.  These 
promptly  become  sclerotic  and  lead  to  aneurysm,  small  or 
large,  single  or  multiple,  or  to  disease  of  the  coronary  arteries. 
It  is  by  these  two  lesions,  therefore,  that  it  is  manifested 
clinically. 

Aortic  Aneurysm. — We  cannot  undertake  to  describe 
aneurysm  of  the  aorta,  but  must  confine  ourselves  to  a  dis- 
cussion of  the  following  pertinent  questions : 

Does  syphilis  cause  aortic  aneurysm? 

What  is  the  frequency  of  syphilitic  aneurysm  and  what 
the  date  of  its  occurrence? 

May  syphilitic  aneurysms  be  recognized  as  such? 

Is  antisyphilitic  treatment  of  any  value? 

Docs  Syphilis  Cause  Aortic  Aneurysm^ — The  statistics  on 
this  subject  are  confusing.  The  syphilographer  does  not  en- 
counter aortic  aneurysm.  Thus,  I  have  seen  a  number  of 
aneurysms  in  one  way  or  another,  yet  my  office  records  of 
syphilitic  cases  show  only  a  single  instance  of  this  condition. 
On  the  other  hand,  when  the  patient  is  seen  with  aneurysm 
he  usually  confesses  to  ancient  syphilis  or  shows  scars  of  the 
disease.  Etienne,^  in  a  series  of  240  cases  of  aneurysm 
(chiefly  aortic),  found  166,  or  sixty-nine  per  cent,  syphilitic, 
and  Malmsten  found  eighty  per  cent  (in  loi  cases). 

Moreover,  other  causes  for  aneurysm  sink  into  relative 
insignificance.  Thus  Etienne  notes  alcoholism  only  28  times, 
and  in  those  northern  countries  where  severe  privation  and 
chronic  alcoholism  are  so  much  more  common  than  in  France, 
aneurysms  are  not  unduly  common. 

Hence  syphilis  is  often  the  apparent  cause  of  aneurysm. 
It  is  not  the  sole  cause,  and  the  pathologist  can  very  rarely 

1  Ann.  de  derinat.  et  syph.,  1897,  vol.  viii,  No.  i. 


488  SYPHILIS    OF    THE    CIRCULATORY    SYSTEM 

demonstrate  typical  syphilitic  tissue  ^  in  the  affected  vessel. 
Yet  that  syphilis  is  the  dominating  etiological  factor  in  the 
production  of  aneurysm  may  be  considered  as  proven.  "  If 
pathology,  gross  or  microscopic,  does  not  always,  or  even 
generally,  show  that  an  aneurysm  is  or  is  not  syphilitic;  if 
specific  treatment  is  often  useless ;  it  is  nevertheless  true  that 
syphilitic  arteritis  is  eminently  calculated  to  prepare  the  ves- 
sel for  aneurysmal  dilatation.  It  would  be  most  surprising  if 
it  did  not  produce  it  "  (Darier  -). 

Frequency  and  Date  of  Incidence. — From  the  evidence 
it  may  be  concluded  that  aortic  and  other  aneurysms  are  rela- 
tively rare  and  late  results  of  syphilis,  otherwise  the  syphilog- 
rapher  would  see  more  of  them.  Yet  Etienne  has  collected  ^2 
cases,  of  which  lo  occurred  in  the  first  five  years,  i8  in  the 
second,  lo  in  the  third,  14  in  the  fourth,  13  in  the  fifth,  and  6 
from  twenty-five  to  forty  years  after  the  initial  lesion.  But 
the  current  clinical  experience  in  this  country  is  that  the  syph- 
ilis is  at  least  ten  years  old  before  the  appearance  of  aneurysm. 

Diagnosis. — Let  us  frankly  admit  that  in  any  given  case 
it  is  impossible  to  state  during  life  whether  the  aneurysm  is 
syphilitic  or  not. 

Treatment. — There  is  no  evidence  that  mercury  is  of  the 
slightest  service  in  the  treatment  of  aneurysm.  Potassium 
iodid  is  unmistakably  serviceable  in  certain  cases ;  yet  even 
so  enthusiastic  a  supporter  of  the  syphilitic  etiology  as  Etienne 
confesses  that  "  Iodid  acts  upon  aneurysms  quite  as  it  does 
upon  other  lesions  due  to  arteriosclerosis." 

SYPHILIS   OF   THE   ARTERIES   OF   THE   EXTREMITIES 

Syphilitic  lesions  of  the  arteries  of  the  extremities  rarely, 
cause  symptoms.     The  clinical  types  are  two,  depending  upon 

'  Cf.  von  Duhring,  Deutsche  med.  Wochenschr.,  1905,  vol.  xxx,  No.  51. 
'  "Syphilis  arterielle,"  Paris,  1904. 


SYPHILIS    OF    THE    VEINS  489 

whether  the  artery  is  weakened  so  as  to  permit  aneurysmal 
dilatation  or  thickened  so  as  to  obstruct  the  circulation  partially 
or  completely.     Thus  we  have — 

Aneurysm,  or  Arterial  Obstruction 

Aneurysm. — The  remarks  made  concerning  aortic  aneu- 
rysm apply  equally  here. 

Arterial  Obstruction. — Depending  upon  the  degree  of  ob- 
struction, the  symptoms  follow  one  of  three  types,  viz. : 

Intermittent  Claudication. — There  is  pain  or  paresthesia 
and  a  tendency  to  cramps  of  the  muscles  of  the  affected  limb, 
increased  by  exercise  and  alleviated  or  entirely  relieved  by  rest. 

Reynaud's  Disease. — That  symmetrical  gangrene  of  the 
extremities  may  be  due  to  syphilis  has  recently  been  suggested 
by  Klotz.i 

Gangrene. — Gangrene  occurs  from  total  occlusion  of  the 
artery.  When  due  to  syphilis  it  is  usually  preceded  by  the 
pain  and  paresthesia  of  intermittent  claudication. 

Diagnosis. — The  test  of  treatment  may  sometimes  prove 
the  syphilitic  nature  of  the  lesions,  just  as  the  history  may 
suggest  it;  but,  as  a  rule,  the  lesion  is  sclerotic  when  attacked, 
and  no  longer  amenable  to  antisyphilitic  medication. 

SYPHILIS    OF    THE    VEINS 

Acute  phlebitis  of  the  superficial  veins  of  the  lower  ex- 
tremities is  one  of  the  rarest  complications  of  early  syphilis 
(cf.  Mendel  -).  It  is  not  clear  that  the  lesion  is  truly  syphi- 
litic.    It  runs  the  usual  course. 

Sclero-gummatous  Phlebitis. — This,  too,  is  extremely 
rare    (cf.    Vaquez^).      It   may   be   sclerotic,    gummatous,   or 

'  Intemat.  Dermat.  Congress  at  New  York,  1907. 

2  Arch.  gen.  de  med.,  1894,  March. 

3  Foumier's  "  Trait6,"  vol.  ii,  Part  II,  p.  890. 


49©  SYPHILIS    OF    THE, CIRCULATORY    SYSTEM 

sclero-gtimmatous.  When  the  lesion  affects  a  superficial  vein 
it  appears  as  a  gumma  or  as  a  mere  hard  fusiform  nodule  in 
the  wall  of  the  vein.  If  a  deep  vein  (portal,  cava,  jugular) 
is  affected,  the  symptoms  are  those  of  pressure  on  adjoining 
structures  or  obstruction  of  the  circulation  (edema,  ascites, 
etc.). 

SYPHILIS   OF    THE    LYMPHATICS 

Apart  from  the  early  lymphangitis  and  lymphadenitis  that 
characterize  the  primary  lesion  and  the  early  period  of  the 
disease  (pages  238,  261),  gumma  of  the  lymph  nodes  is  the 
only  lesion  to  arrest  attention.  It  is  not  extremely  uncom- 
,  mon,  and  the  following  cases,  which  I  have  recently  published,^ 
sufficiently  describe  its  symptoms  and  diagnostic  features : 

The  first  patient,  a  man  forty-eight  years  of  age,  with  no 
previous  history  of  syphilis,  complained  of  a  hard,  irregular 
tumor  of  the  cervical  lymph  nodes  below  and  behind  the  angle 
of  the  jaw.  Examination  revealed  an  enlarged,  ulcerated 
tonsil  directly  connected  with  the  growth.  A  few  weeks  of 
vigorous,  antisyphilitic  treatment  failing  to  have  any  effect, 
it  was  promptly  removed,  and  proved  to  be  a  mixed-celled 
sarcoma  of  the  tonsil. 

A  few  weeks  later  I  saw  a  patient  in  the  third  year  of  his 
syphilis,  who  had  been  quite  constantly  under  treatment,  and 
had,  upon  the  left  side  of  his  neck,  a  swelling  of  the  lymph 
nodes,  at  first  sight  almost  identical  with  that  of  the  previous 
case.  Neither  was  particularly  painful,  and  their  degree  of 
hardness  was  about  the  same.  But  in  this  latter  case  there 
was  no  involvement  of  the  tonsil ;  there  was  a  large  submental 
lymph  node  which  rapidly  broke  down  and  discharged  a 
watery  pus,  and  on  the  opposite  side  of  the  neck  there  was 
slight  enlargement  of  the  corresponding  node.  The  history 
of  syphilis,  the  bilateral  lesion,  the  rapid  growth  and  ulcera- 

*  "Bryant  and  Buck's  Surgery,"  vol.  ii. 


SYPHILIS    OF    THE    LYMPHATICS  491 

tion  of  the  submental  lymph  node  made  the  diagnosis  of 
syphilis,  which  was  confirmed  by  the  success  of  treatment. 

At  the  time  when  I  was  treating  this  latter  case  I  had 
under  my  care  a  third  man,  an  alcoholic,  who,  although  in 
the  first  year  of  his  syphilis,  had  very  rebellious,-  diffuse, 
tubercular  syphilids.  While  these  were  disappearing  under 
treatment,  there  suddenly  appeared  a  large,  tender  swelling 
of  the  inguinal  lymph  nodes,  most  marked  upon  the  left  side. 
Examination  of  the  preputial  cavity  revealed  a  number  of 
mucous  patches  and  a  disgusting  state  of  filth.  Cleanliness 
and  an  antiseptic  powder,  together  with  the  general  treatment 
of  syphilis,  which  was  being  vigorously  pushed,  promptly 
cured  the  mucous  patches,  and  the  swollen  nodes  in  due  time 
subsided. 

The  chain  of  causes  in  this  instance  was  characteristic. 
First,  the  dirt  under  the  prepuce  caused  the  mucous  patches 
by  its  irritation ;  then  the  mucous  patches  emitted  an  acrid 
secretion,  which  caused  balanitis,  of  which  the  secondary 
adenitis  in  the  groin  was  the  first  sign;  and,  finally,  cleansing 
of  the  dirt  and  a  little  antisepsis  were  the  means  of  cure,  the 
mercurial  treatment  not  being  changed  in  any  way. 


CHAPTER    XXXIV 
SYPHILIS  OF  VARIOUS  VISCERA 

SYPHILIS   OF   THE    DIGESTIVE    ORGANS 

Syphilis,  though  it  often  strikes  the  Hver,  the  mouth,  and 
the  pharynx,  usually  spares  the  rest  of  the  digestive  tract 
and  its  associated  glands. 

Salivary  Glands,  Pancreas. — Gumma  and  diffuse  syphi- 
litic sclerosis  may  occur  in  any  of  the  salivary  glands  ^  or  in 
the  pancreas,-  but  these  lesions  are  pathological  curiosities. 
That  syphiloma  of  the  pancreas  may  cause  glycosuria  is  pos- 
sible. Lancereaux  states  that  such  glycosuria  assumes  little 
clinical  importance.  (It  is  noted  six  times  in  our  cases — at 
six,  fifteen,  twenty-four  (twice),  and  twenty-five  years  from 
the  chancre,  and  once  after  an  unrecorded  interval.) 

Esophagus.  —  Very  rare.  Gastou  ^  distinguishes  three 
clinical  types : 

"  I.  The  latent  type  shows  no  characteristic  symptoms. 
The  course  is  rapid.  There  is  at  first  slight  interference  with 
deglutition,  then  grave  dysphagia,  generally  in  a  case  of 
malignant  or  grave  syphilis.  Then  rapidly  ensue  weakness, 
emaciation,  cachexia,  and  death.  ... 

"  2.  Dysphagia  or  guttural  type.  In  cases  of  this  type 
there  are  pharyngeal  lesions  (gumma,  infiltration,  ulceration) 
near  the  orifice  of  the  esophagus.  Swallowing  causes  painful 
spasm  and  regurgitation. 

»  Chatin  in  Foumier's  "  Traite,"  vol.  ii,  Part  II,  p.  559. 
2  Bensaude,  ihid.,  p.  566. 
'Ibid.,  p.  465. 
492 


INTESTINAL    SYPHILIS  493 

"  3.  Stricture.  This  is  the  least  rare  and  the  most  typical 
lesion.  It  begins  with  dysphagia  .  .  .  but  without  vomiting 
or  pressure  symptoms.  .  .  .  The  passage  of  a  bougie  is  ob- 
structed at  the  level  of  the  first  ring  of  the  trachea  or  at  the 
termination  of  the  esophagus.  .  .  .  The  passage  of  the  instru- 
ment gives  no  relief  to  the  patient.  The  obstruction  may  be 
relieved  by  mixed  treatment  or  by  gastrostomy." 

SYPHILIS   OF   THE    STOMACH 

Syphilis  of  the  stomach  is  almost  as  rare  as  syphilis  of 
the  esophag^is.  In  our  records  it  does  not  appear.  But  a 
few  autopsies  and  clinical  histories  prove  that  gummatous 
infiltration  and  ulceration  may  occur/  and  that  this  condition 
is  distinguishable  during  life  from  the  conditions  which  it 
simulates  only  by  the  fact  that  it  resists  all  other  treatments, 
but  may  be  rapidly  and  brilliantly  relieved  by  mercury  and 
iodids. 

Clinically,  Morgan  distinguishes  four  types,  imitating  re- 
spectively chronic  gastritis,  ulcer,  stenosis,  and  carcinoma. 
Hence  these  diseases  must  be  added  to  those  in  which  the 
possibility  of  syphilis  must  be  considered,  and  for  the  cure  of 
which — if  all  else  fail — mixed  treatment  should  be  given  on 
the  bare  chance  that  it  may  cure. 

INTESTINAL    SYPHILIS 

Syphilis  of  the  intestine  (except  the  rectum),  like  syphilis 
of  the  stomach,  imitates  more  familiar  conditions  (such  as 
diarrhea,  tumor,  stricture),  from  which  it  may  be  distin- 
guished during  life  only  by  the  therapeutic  test.  The  one  case 
of  suspected  intestinal  syphilis  on  our  list  has  already  been 
cited  (page  100). 

*  Gerry  Morgan,  Am.  Med.,  1906,  vol.  xii,  p.  123. 


494 


SYPHILIS   OF   VARIOUS   VISCERA 


Gaucher  alleges  syphilis  as  a  probable  cause  of  appendi- 
citis— at  least,  of  32  Frenchmen  who  had  had  appendicitis 
before  coming  to  him,  8  gave  a  history  of  acquired  syphilis, 
and  21  of  hereditary,  syphilis. 

SYPHILIS    OF    THE    RECTUM 

That  syphilis  of  the  rectum  assumes  so  important  a  place 
in  the  mind  of  the  general  practitioner  is  due  to  the  insistence 
of  Professor  Fournier,  rather  than  to  its  frequency  or  clinical 
importance. 

Apart  from  the  chancres  and  secondary  lesions  that  may 
encroach  upon  the  anus  and  the  lower  inch  of  the  bowel,  we 
may  recognize : 

1.  Gumma. — Most  exceptional. 

2.  Ulcers. — Very  rare,  usually  confined  to  the  ultimate 
inch  or  two  of  the  bowel,  sometimes  associated  with  similar 
lesions  higher  up. 

3.  Ano-rectal  Syphiloma. — This  lesion,  though  said  to  be 
much  more  common  than  gumma  or  ulceration,  is,  neverthe- 
less, very  rare.     We  have  record  of  but  one  case. 

The  lesion  consists  of  a  "  hyperplastic  infiltration  of  the 
ano-rectal  wall"  (Fournier).  The  infiltration  may  be  con- 
fined to  the  rectum,  in  which  case  it  affects  the  region  within 
or  just  above  the  internal  sphincter.  It  is  never  found  higher 
up  the  bowel.  It  consists  in  a  diffuse  cylindrical  rigidity  of 
the  rectal  wall  (a  stricture),  an  inch  or  two  in  breadth,  ad- 
mitting the  finger  (perhaps  with  some  difficulty),  and  not 
ulcerated  upon  its  surface. 

It  may,  on  the  other  hand,  be  ano-rectal  or  exclusively 
anal.  At  the  anus  it  bulges  out  in  a  hard,  indurated, 
pseudo-condylomatous  mass  which  may  undergo  secondary 
erosion. 

The  progress  of  the  lesion  is  slow.     Though  it  may  be 


SYPHILIS    OF   THE    URINARY   ORGANS  495 

checked  by  being-  seen  early,  it  usually  terminates  in  a  perma- 
nent cicatricial  deg-eneration ;  it  becomes  a  true  stricture. 

4.  Syphilitic  Rectal  Stricture. — The  loose  denomination 
of  every  rectal  stricture  in  a  person  who  has  had  syphilis,  as 
a  syphilitic  stricture,  is  utterly  unwarranted.  Surgeons  who 
permit  themselves  this  liberty  find  that  most  of  their  so-called 
syphilitic  rectal  strictures  occur  in  women,  and  at  a  depth  of 
from  two  to  four  inches  up  the  bowel,  while  Fournier — than 
whom  no  one  could  be  more  enthusiastic  on  this  subject — has 
seen  eleven  strictures  in  men  to  three  in  women,  and  finds 
them  all  in  the  lozver  tzvo  inches  of  the  rectum.  The  strictures 
higher  up  are  properly  attributable  to  such  causes  as  pelvic 
cellulitis,  retroversion,  trauma  in  parturition — all  peculiar  to 
women  and  bearing  no  relation  to  syphilis. 

These  strictures  are  as  rare  as  the  syphiloma  that  causes 
them. 

The  treatment  by  mercury  and  iodid  should  be  tried,  in 
the  hope  that  what  appears  to  be  cicatricial  tissue  may  still 
contain  enough  active  syphiloma  to  be  favorably  influenced 
by  these  remedies.  If  these  fail,  dilate  or  incise,  and  give 
no  very  optimistic  prognosis,  for  recontraction  is  the  rule. 

SYPHILIS    OF    THE    URINARY    ORGANS 

Syphilis  of  the  Kidney. — Syphilis  of  the  kidney,  though 
abundantly  proven  to  exist,  is  still  in  the  category  of  patho- 
logical curiosities. 

Reference  to  Karvonen's  ^  classic  work  reveals  evidence 
that  every  form  of  nephritis  may  result  from  syphilis. 

In  the  earlier  stages  of  the  disease  there  may  be  some 
slight  congestion  evinced  only  by  a  transitory  albuminuria, 
or  the  lesions  may  be  much  graver,  and  even  amount  to  an 

'  Zeitschr.  /.  Derm.,  1898. 


496  SYPHILIS   OF   VARIOUS    VISCERA 

acute,  diffuse  nephritis,  in  which  either  parenchymatous  or 
interstitial  lesions  predominate.  In  the  later  years  -of  the  dis- 
ease chronic  diffuse  nephritis  and  amyloid  kidney  occur;  ex- 
ceptionally there  is  sclerosis,  or  gumma,  or  sclero-gumma. 
These  last  conditions,  though  characteristic  of  syphilis  to  the 
pathologist,  rarely  offer  a  clinical  picture  permitting  a  diag- 
nosis. Finally,  it  is  alleged  that  hemoglobinuria  occurs  oftenest 
in  syphilitic  patients,  and  certain  brilliant  cures  of  this  condi- 
tion by  mercury  or  iodids  are  alleged  as  proof  of  its  syphi- 
litic origin.  • 

We  may  group  all  these  lesions  under  two  heads :  the  one 
medical,  including  albuminuria,  hemoglobinuria,  diffuse  ne- 
phritis, acute  or  chronic,  whether  predominantly  parenchyma- 
tous or  interstitial,  amyloid  kidney,  and  sclerosis  of  the  kidney  ; 
under  the  other,  or  surgical  head,  we  may  place  gumma  of 
the  kidney.  Of  the  former  class  it  may  be  said  that,  with  the 
exception  of  certain  sclerotic  cases,  they  possess  no  patho- 
logical characteristics  to  stamp  them  as  exclusively  syphilitic 
or  to  differentiate  them  from  similar  conditions  due  to  other 
causes.^  Clinically  speaking,  these  medical  conditions  are 
often  attributed  to  syphilis  solely  because  they  are  discovered 
in  a  syphilitic  subject.  But  when  we  consider  the  frequency 
of  nephritis,  especially  chronic  nephritis,  in  every  walk  of  life, 
and  add  the  special  liability  to  nephritis  which  must  exist 
in  patients  who  die  avowedly  syphilitic,  especially  in  those 
hospital  cases  that  reach  the  post-mortem  table,  it  is  small 
wonder  that  so-called  syphilitic  nephritis  (i.  e.,  nephritis  in  a 
syphilitic  patient),  as  noted  by  the  pathologist,  is  extremely 
common. 

Take,  for  example,  Spiess's  figures,  compiled  from  autop- 
sies made  between  1866  and  1875  at  the  Charity  Hospital  in 

■  Syphilis  of  the  renal  arteries  can  sometimes  be  distinguished  as  the  under- 
lying cause  of  chronic  nephritis;  but  it  is  by  no  means  easy  in  the  kidney  to 
distinguish  syphilitic  arteritis  from  arterial  sclerosis  due  to  other  cause. 


SYPHILIS    OF   THE    URINARY   ORGANS  497 

Berlin.     Among  220  syphilitics  he  found  the  kidneys  sound 
in  only  62  cases.     In  the  remaining  patients  he  found : 

Amyloid  kidney 42  times 

Parenchymatous  nephritis 21  " 

Sclerosis  of  the  kidney 18  " 

Interstitial  nephritis 16  " 

Atrophy  of  the  kidney 11  " 

Sclero-gummatous  kidney 7  " 

Various  inflammations  only  partially  attribu- 
table to  syphilis 16  " 

But  the  clinician  very  rarely  comes  upon  nephritis  attrib- 
utable to  syphilis.  One  would  expect  acute  nephritis  to  be  a 
common  complication  of  so  virulent  an  infection  as  early 
syphilis  sometimes  is;  yet  it  is  surprisingly  rare.  I  do  not 
remember  to  have  seen  any  symptoms  of  nephritis  in  the.  early 
stages  of  syphilis  beyond  the  appearance  in  the  urine  of  a 
little  albumin  and  a  few  casts.  In  the  later  years  of  the  dis- 
ease, however,  nephritis  is  quite  common;  but  it  is  almost 
always  of  that  latent,  chronic  type  which  shows  itself  only 
by  the  presence  of  albumin  and  casts,  a  slightly  decreased 
output  of  solids,  and  no  active  subjective  symptoms.  The 
difficulty  which  constantly  arises  in  the  clinical  management 
of  such  cases  is  to  decide  whether  the  nephritis  is  due  to  the 
disease,  to  its  treatment  by  mercury  or  iodids,  or  to  outside 
causes.  I  am  strongly  inclined  to  attribute  the  chronic  nephri- 
tis I  see  in  the  later  years  of  syphilis  to  overtreatment  and 
alcoholism  rather  than  to  the  disease  itself. 

Reference  has  already  been  made  to  the  toxic  effect  of 
mercury  upon  the  kidney  and  to  the  manifest  danger  of  ex- 
hibiting it  in  high  doses  if  the  kidneys  are  not  sound.  On 
the  other  hand,  the  treatment  necessary  to  the  cure  of  the 
average  case  of  syphilis  does  not  the  least  damage  to  the 
kidneys;  and  if  twenty-five  per  cent  of  all  cases  of  syphilis 
die  with  chronic  nephritis  (Karvonen)  this  is  probably  attrib- 


498  SYPHILIS   OF   VARIOUS   VISCERA 

utable  only  in  some  measure  and  indirectly  (through  arterial 
sclerosis)  to  the  disease,  and  often  to  the  excesses,  the  depri- 
vations, and  the  other  nocive  circumstances  which  have  had 
a  share  in  terminating  the  patient's  life. 

Diagnosis. — Syphilis  of  the  kidney  may  be  suspected  if 
a  patient  develops  albuminuria  or  symptoms  of  nephritis  dur- 
ing the  course  of  his  syphilis.  As  Mauriac  (quoted  by  Ber- 
dal)  says:  "Once  it  is  proven  that  the  (nephritic)  patient 
has  had  syphilis,  we  must  estimate  this  as  a  factor  of  prime 
importance;  not  that  it  (syphilis)  is  the  most  important  cause 
of  Bright's  disease,  but  because  it  gives  us  hope  and  a  thera- 
peutic indication.  .  .  .  The  insignificance,  the  fewness  of  the 
early  manifestations,  and  the  long  period  which  has  elapsed 
without  the  appearance  of  any  syphilitic  accidents,  none  of 
these  things  impair  the  force  of  this  precept,  and  we  must 
respect  it  even  in  those  cases  in  which  the  action  of  syphilis 
upon  the  kidney  appears  problematic  and  subordinated  to 
graver  and  more  proximate  pathogenic  influences." 

The  test  of  treatment  may  be  applied  to  confirm  or  refute 
the  suggestion.  But  the  usual  regulations  of  diet,  etc.,  should 
not  be  neglected,  and  clinically  only  those  cases  may  be  con- 
sidered proven  of  syphilitic  origin  in  which  a  cure  is  effected 
by  antisyphilitic  treatment  alone,  after  the  strictest  milk  diet 
and  attention  to  other  therapeutic  precautions  have  failed. 
Such  cases  are  as  rare  as  white  blackbirds. 

Treatment. — In  spite  of  the  recognized  irritating  effect 
of  mercury  upon  the  kidney,  the  few  cures  of  syphilitic  nephri- 
tis that  have  been  obtained  are  attributable  to  mercurial  treat- 
ment; but  the  mercury  must  be  administered  cautiously,  its 
effect  upon  the  urine  being  checked  by  almost  daily  urinalysis. 
It  is  preferable  to  spare  the  digestion,  and  not  to  risk  the 
sudden  explosion  of  mercurial  poisoning  which  is  always  pos- 
sible when  mercury  is  given  either  by  fumigation  or  by  inunc- 
tion.    The  injection  of  insoluble  salts  is  also  too  violent,  and 


SYPHILIS   OF   THE    URINARY   ORGANS  499 

the  best  method  of  treatment  is  by  the  injection  of  soluble 
salts,  beginning  at  about  half  the  usual  dose  and  increasing 
carefully  and  slowly.  If  some  two  weeks  of  such  treatment 
produce  no  effect,  iodid  may  be  administered  in  doses  not 
higher  than  gr.  xx  or  xxx  (2  gm.)  a  day  for  three  weeks; 
and  if  at  the  end  of  this  time  nothing  has  been  achieved,  the 
theory  that  syphilis  is  the  cause  of  the  nephritis  may  be 
dropped — at  least  it  is  fairly  proven  that  antisyphilitic  treat- 
ment will  do  no  good. 

ScLERO-GUMMATOUS  NEPHRITIS. — This  type  of  Icsiou  wc 
have  dubbed  "surgical"  because  its  symptoms  (if  it  produce 
any)  suggest  surgical  disease  of  the  kidney,  either  neoplasm 
or  tuberculosis.  The  lesion  is  usually  confined  to  one  kidney ; 
the  gummata  may  be  large  and  single  or  smaller  and  multiple. 
They  begin  usually  in  the  cortex,  and,  after  growing  to  a  con- 
siderable size,  burst  within  the  pelvis  of  the  kidney  and  dis- 
charge through  the  urinary  organs. 

The  sclerotic  process,  like  that  in  the  liver,  is  usually 
widespread  in  the  form  of  bands  of  scar  tissue  radiating 
from  sclerotic  or  gummatous  centers.  The  sclerosis  may  be 
slight  and  partial  or  general,  and  may  be  sufficiently  wide- 
spread to  cause  atrophy  of  the  organ;  but  the  renal  par- 
enchyma between  the  areas  of  sclerosis  is  usually  practically 
normal. 

Gumma  of  the  kidney  does  not  occur  before  the  fourth 
or  fifth  year  of  the  disease,  but  may  occur  at  any  time  there- 
after. It  is  usually  associated  with  other  visceral  syphilitic 
lesions. 

Symttoms. — Sclerosis  of  the  kidney  without  gumma  can 
only  be  diagnosed  on  autopsy.  It  gives  no  symptoms  to  dif- 
ferentiate it  from  other  forms  of  chronic  nephritis ;  nor  does 
gumma  give  any  symptoms  until  it  has  either  grown  to  a 
considerable  size  or  has  burst  into  the  pelvis  and  given  rise 

to  pyuria. 
34 


500 


SYPHILIS   OF   VARIOUS   VISCERA 


The  following  cases  reported  by  Israel  ^ — the  one  mis- 
taken for  tumor,  the  other  for  tuberculosis — sum  up  admirably 
the  present  status  of  our  knowledge  of  gumma  of  the  kidney : 

Case  XXXVI. — In  October,  1888,  Israel  was  consulted  by 
a  woman,  twenty-three  years  old,  on  account  of  a  tumor  of  the 
right  kidney.  She  had  been  married  four  years  and  had  borne 
three  children,  of  whom  the  first  died  in  twenty-three  days  and 
the  second  in  one  year. 

In  March,  1888,  she  had  bilateral,  syphilitic  iritis.  In  June 
she  was  delivered  of  a  healthy  child.  For  four  weeks  she  had 
suffered  from  frequent  urination  and  abdominal  and  pelvic  pains, 
and,  for  two  weeks,  from  a  sharp  pain  in  the  right  side,  without 
cough.  The  urine  was  normal.  The  right  kidney  was  large, 
hard,  sensitive,  and  immovable.  The  urine  was  increased  in  vol- 
ume, of  low  specific  gravity,  and  contained  a  few  leucocytes  and 
bacteria,  once  a  hyaline  cast,  and  sometimes  albumin  and  some- 
times not.  Continued  pressure  on  the  kidney  markedly  increased 
the  epithelial  sediment  and  caused  slight  bleeding.  Repeated  ex- 
periments of  this  kind  produced  a  slight  but  definite  decrease  in 
the  volume  of  the  tumor. 

A  course  of  iodids  proved  futile,  and  on  January  22d  neph- 
rectomy was  performed.  The  fatty  capsule  was  found  edema- 
tous, scarred,  and  adherent.  The  kidney  was  found  apparently 
normal  in  its  upper  two  thirds,  while  the  lower  end  was  occupied 
by  a  hard  growth.  It  was  therefore  removed.  Section  of  the 
kidney  showed  syphilitic  and  interstitial  nephritis  and  hyper- 
plastic perinephritis.  After  operation  the  patient  gained  forty 
pounds,  and  bore  a  healthy  child  within  a  year,  while  the  urine 
continued  to  show  albumin  from  time  to  time  for  five  years  in 
spite  of  iodids.  Since  then  the  patient  has  been  well  and  has 
borne  several  children. 

Case  XXXVII. — The  patient,  a  man,  thirty  years  old,  had 
lost  two  brothers  of  phthisis.  He  had  had  a  chancre  many  years 
before,  and  had  been  treated  with  mercury.  In  May,  1889,  he 
began  to  have  continuous  pain  in  the  left  side.  Six  months  later 
he  began  to  have  short,  sharp  pains  every  hour  or  so.  Then  a 
redness  appeared  over  the  tenth  rib  in  the  axillary  line,  and  three 

1  "  Chirurgie  der  Nieren." 


SYPHILIS   OF   THE    PELVIC    ORGANS  501 

weeks  later  a  supposed  abscess  of  the  spleen  was  incised.  Four- 
teen months  later,  in  December,  1890,  the  patient  consulted 
Israel,  who  found  a  dififuse,  adherent  growth  in  the  region  of 
the  kidney,  in  front  of  which  the  spleen  could  be  made  out,  dis- 
tinct and  movable,  while  a  fistula  led  between  the  eleventh  and 
twelfth  ribs  into  the  tumor.  The  urine  was  purulent  and  albu- 
minous ;  tubercle  bacilli  could  not  be  found  in  it. 

January  3,  1890. — Nephrectomy  for  Tuberculous  Kidney. — 
The  fistula  was  followed  down  after  resection  of  the  eleventh 
and  twelfth  ribs,  and  the  kidney  isolated  with  great  difficulty 
from  the  dense,  perinephritic  scar.  The  wound  healed  extremely 
slowly,  but  the  patient  gained  weight  and  was  apparently  well 
in  1900.  Investigation  showed  gummatous  degeneration  of  the 
kidney. 

In  either  case  the  diagnosis  of  gumma  might  have  been 
made  had  there  been  other  prominent  lesions  of  syphilis;  and 
in  the  former  case  one  cannot  but  feel  that  perhaps  a  course 
of  mercurial  injections  would  have  succeeded  where  the  iodids 
failed.  But  it  is  doubtful  whether  any  better  treatment  could 
have  been  devised  for  either  than  the  removal  of  the  kid- 
ney. To  say  that  every  case  of  pseudo-tuberculous  kidney 
which  shows  no  typical  bacilli  in  the  urine,  and  in  which  the 
history  suggests  tuberculosis  rather  than  syphilis,  should  be 
submitted  to  a  test  course  of  treatment  is  to  enunciate  a  plati- 
tude that  would  very  rarely  yield  any  good  results. 

SYPHILIS   OF    THE    PELVIC    ORGANS 

Syphilis  of  the  Bladder.— The  known  cases  of  syphilis  of 
the  bladder  are  three,  two  of  them  published  by  Margoulies 
and  one  by  Le  Fur;  ^  each  of  the  three  was  manifestly  syphi- 
litic. Two  of  them  showed  sloughing  ulcers  near  the  ureteral 
orifices;  the  third,  three  small  tumors  in  the  same  region;  all 
three  w^ere  promptly  cured  by  antisyphilitic  treatment. 

*  Guyon's  Ann.,  1902,  vol.  xx,  p.  385. 


502 


SYPHILIS   OF   VARIOUS   VISCERA 


Paralysis  of  the  bladder  due  to  spinal  syphilis  need  only 
be  mentioned. 

Syphilis  of  the  Prostate  and  Seminal  Vesicles.— Nogues  ^ 

relates  several  suggestive  cases,  but  nothing  convincing. 

Pelvic  Cellulitis.  — Fournier  -  has  reported  the  following 
case: 

Case  XXXVIII. — "  Last  December  I  saw,  in  consultation,  a 
patient,  thirty-four  years  of  age,  said  to  have  a  tumor  of  the 
pelvis,  which  had  been  diagnosed  as  an  inoperable  sarcoma  by 
three  members  of  the  Faculty.  I  was  asked  if  there  was  not  some 
possibility  that  this  lesion  was  syphilitic  in  origin,  though  the 
patient  denied  all  syphilitic  antecedents. 

"  I  found  the  patient  pale,  thin,  debilitated,  almost  cachectic. 
For  several  months  he  had  suffered  a  vague  discomfort  in  the 
pelvis,  with  symptoms  of  progressively  increasing  vesico-rectal 
compression.  .  .  .  Recto-abdominal  palpation  revealed  a  volu- 
minous infiltration  lining  the  pelvic  cavity  and  extending  out  of 
it  in  front  and  to  the  left  side.  .  .  .  The  tumor  seemed  to  be 
reflected  over  the  bladder  while  the  rectum  was  free  below,  but 
was  surrounded  higher  up  by  the  pelvic  infiltrate,  and  permitted 
the  passage  of  a  finger  only  with  difficulty  and  pain.  .  .  . 

"  No  personal  history  or  evidence  of  syphilis ;  but  in  the  fam- 
ily a  singular  mortality.  Of  the  patient's  fifteen  brothers  and 
sisters,  twelve  died,  most  of  them  in  infancy.  .  .  .  No  stigmata 
whatever  of  hereditary  syphilis.  I  asked  that  an  ophthalmo- 
scopic examination  be  made  as  soon  as  possible.  Then — and 
here  begins  the  picturesque  part  of  the  narration — only  a  few 
hours  had  passed  after  this  consultation,  when  a  gentleman  called 
upon  me,  none  other  than  the  elder  brother  (thirty-six  years  old) 
of  the  patient.  *  I  come  for  two  reasons,'  said  this  gentleman. 
'  I  bring  you  the  information  that  you  may  feel  almost  certain 
my  father  was  syphilitic ;  moreover,  I  myself  am  anxious,  seeing 
the  malady  of  my  brother.  I  therefore  beg  you  to  examine  me 
and  to  tell  me  whether  I  have  anything  to  fear.'  You  may  pic- 
ture the  haste  with  which  I  took  advantage  of  this  unforeseen 


'  Nogues  in  Fournier,  vol.  ii,  Part  II,  p.  667. 
2  Bull,  de  I'acad.  de  med.,  1902,  October  21. 


SYPHILIS    OF    THE    PELVIC    ORGANS  503 

circumstance.  I  examined  this  gentleman  and  searched  him  with 
the  most  scrupulous  care  for  evidences  of  specific  heredity;  but 
upon  him,  as  upon  his  brother,  I  found  nothing — absolutely  noth- 
ing to  awaken  any  suspicion.  The  examination  of  his  eyes 
remained.  I  sent  him  to  the  same  ophthalmologist  (Dr.  Anto- 
nelli)  who  was  to  examine  his  brother.  The  following  day  I 
received  from  Dr.  Antonelli  a  note,  which  I  may  sum  up  as 
follows:  '  (i)  In  your  first  patient  (with  the  pelvic  lesion)  noth- 
ing but  slight  stigmata  of  the  fundus — suspicion  but  not  proof 
of  hereditary  syphilis.  (2)  On  the  other  hand,  his  older  brother 
shows  positive  stigmata  of  syphilis  (chorio-retinitis).' " 

We  may  sum  up  briefly  the  remainder  of  the  narration. 
A  course  of  mixed  treatment  showed  marked  results  in  ten 
days,  and  after  two  months  the  whole  infiltrate  had  been  ab- 
sorbed; the  patient  had  gained  eight  kilos,  and  was  entirely 
well. 

Syphilis  of  the  Ovaries  and  Uterus. — Lesions  of  the 
internal  genitals  of  the  female  come  in  the  class  of  rare  and 
obscure  visceral  lesions,  sclerotic  and  gummatous,  of  which 
there  are  a  few  autopsy  findings  and  a  number  of  alleged  cures 
by  mixed  treatment  (e.  g.,  of  metrorrhagia  ^). 

1  Semaine  med.,  1907,  vol.  xxvii,  No.  8. 


CHAPTER    XXXV 
HEREDITARY  SYPHILIS  IN   UTERO   AND  IN  INFANCY^ 

Chapter  VI,  oh  Syphilitic  Inheritance,  is  an  introduc- 
tion to  the  study  of  hereditary  syphiHs,  the  details  of  which 
need  not  be  repeated;  we  may  add,  however,  the  following 
figures  derived  from  the  statistics  of  authors  who  accept 
the  theory  of  paternal  heredity  (as  indeed  almost  everyone 
does). 

Hochsinger  reports  y2  families  in  which  the  father  alone 
was  known  to  be  syphilitic;  thirty-five  per  cent  of  them  had 
no  stillbirths  or  abortions.  To  the  remaining  sixty-five  per 
cent  there  there  were  born  no  children  who  were  dead  at 
birth  or  died  soon  thereafter,  while  197  lived. 

Fournier  reports  that  paternal  syphilitic  heredity  causes 
sixty-seven  per  cent  of  the  children  to  be  syphilitic  and  twenty- 
eight  per  cent  to  die;  maternal  heredity  produces  eighty-four 
per  cent  syphilitic  and  sixty-eight  per  cent  deaths,  while  mixed 
heredity  (both  parents  syphilitic)  produces  ninety-two  per 
cent  syphilitic  children  with  68.5  deaths. 

Le  Pileur  reports  a  hospital  experience  of  567  pregnancies 
of  syphilitic  women  with  174  abortions. 

Thus  the  most  striking  effect  of  hereditary  syphilis  is  its 
polymortality  among  infected  children,  while  the  dangers  of 

1  Reviewed  by  Dr.  John  Howland.  The  most  important  recent  works 
upon  this  subject  are  E.  Fournier,  "I'Heredo-syphilis";  and  Hochsinger,  in 
Handbuch  d.  Kinder heilkunde;  Pfaundler  and  Schlossmann,  1906,  vol.  i, 
p.  894. 

504 


HEREDITARY   SYPHILIS    IN    UTERO   AND    IN    INFANCY     505 

infection  to  the  child,  already  dwelt  upon  in  Chapter  VI,  are 
thus  stated  by  Fournier : 

"  I.  The  danger  of  syphilitic  inheritance  varies  greatly 
with  the  age  of  the  disease  in  the  parent,  but  shows  a  maxi- 
mum— and  that  a  marked  one — corresponding  to  the  first  three 
years  of  infection. 

"  2.  The  maxirfium  of  this  maximum  corresponds  approx- 
imately to  the  first  year. 

"  3.  Beyond  the  first  three  years  of  the  disease  there  is  a 
decreasing  danger,  but  infinitely  less  marked. 

"  4.  Syphilitic  heredity  has  occurred  in  the  sixth,  the 
eighth,  the  tenth,  the  twelfth  years,  even  the  fifteenth,  and 
perhaps  the  seventeenth,  the  eighteenth,  and  the  twentieth, 
which  appears  to  be  the  extreme  limit." 

The  important  features  of  hereditary  syphilis  may  be  sub- 
divided as  follows  (Hochsinger)  : 

1.  Fetal  syphilis. 

2.  Infantile  syphilis  (first  three  to  six  months). 

3.  Relapses  in  infancy  (until  the  fifth  year). 

4.  Late  hereditary  syphilis. 

The  importance  of  these  stages  decreases  throughout  the 
series.  Thus  fetal  syphilis  is  fatal  to  about  one  half  the  in- 
fected children.  Infantile  syphilis  kills  fully  half  as  many 
more  in  the  first  three  months  of  extra-uterine  life.  The  later 
relapses  in  infancy  are  less  frequent,  less  severe,  and  rarely 
fatal,  while  the  so-called  "  late "  or  "  delayed "  hereditary 
syphilis,  which  occurs  after  the  fifth  or  sixth  year,  differs  in 
no  respect  from  tertiary  syphilis  in  the  adult.  But  the  adult 
who  has  suffered  hereditary  syphilis  in  infancy  bears  upon 
his  body  certain  evidences  of  the  storm  that  has  passed. 
These  form  a  fifth  division : 

5.  Stigmata  of  hereditary  syphilis. 


5o6     HEREDITARY    SYPHILIS    IN    UTERO    AND    IN    INFANCY 

FETAL    SYPHILIS 

Pathology. — The  pathology  of  fetal  syphilis  differs  from 
the  same  process  in  the  adult  chiefly  in  its  hyperacuteness. 
In  the  adult  the  disease  localizes  itself  here  and  there  in  small 
areas  and  shows  a  special  affinity  to  the  skin  and  mucous 
membranes,  and  later  to  the  nervous  system,  the  underlying 
process  being  always  specific  arterial  disease.  But  in  the. 
fetus  the  chief  localizations  are  in  the  viscera,  and  secondly 
in  the  bones;  the  skin  is  immune  until  just  before  or  just 
after  birth.  Moreover,  the  hyperacuteness  of  the  process  is 
shown  in  its  diffusion  throughout  an  organ,  contrasting  strik- 
ingly with  the  circumscribed  visceral  involvement  in  the  adult. 

The  viscera  most  frequently  and  most  markedly  affected 
are,  in  order  of  importance,  the  lungs,  the  liver,  the  kidney, 
and  the  spleen. 

"  The  type  of  congenital  syphilis  is  a  diffuse  cell  pro- 
liferation arising  from  the  perivascular  connective  tissue  of 
the  smallest  vessels,  so  that  the  solitary  syphiloma  is  very  rare 
in  the  fetus  and  the  infant. 

"  The  infiltration  is  exclusively  a  diffuse  one  arising  from 
the  smallest  vessels  in  the  organ,  with  a  special  tendency  to 
later  contraction  and  obliteration  of  these  vessels.  The  peri- 
vascular proliferation  begins  in  a  sleevelike  way  in  the  adven- 
titia  and  extends  outward  into  the  connective  tissue,  less  often 
into  the  inner  wall  of  the  artery,  thus  obliterating  it.  In  all 
the  diseased  organs  one  finds  here  and  there  dense  cell  accu- 
mulations visible  to  the  naked  eye  and  spoken  of  as  '  miliary 
syphilomata  '  or  '  gummata.' 

"  In  the  affected  organs  we  find  checked  development  of 
the  parenchyma,  abnormal  development  of  the  Malpighian 
bodies,  persistent  epithelial  rests  and  canals,  cystic  develop- 
ment of  the  cortex  of  the  kidney,  etc.  Thus  the  hyperplasia 
of  the  connective  tissue  goes  hand  in  hand  with  a  hypoplasia 


FETAL    SYPHILIS  507 

of  the  parenchyma.  These  changes  can  often  not  be  made 
out  macroscopically,  and  we  note  only  an  increase  in  volume 
and  density  of  the  liver  and  spleen.  The  liver  always  shows 
considerable  interstitial  infiltration,  the  connection  of  which 
with  the  vascular  system  is  very  marked.  One  often  finds 
pinhead,  yellowish  masses  of  necrotic  liver  cells  surrounded 
by  areas  of  marked  congestion.  This  is  an  anemic  necrosis. 
Similar  conditions  are  seen  in  the  kidney,  the  suprarenal  and 
the  epiphyseal  line  of  the  bones;  indurative  thickening"  of 
spleen  and  pancreas ;  lack  of  development  of  the  kidney  cortex 
with  rudimentary  Malpighian  bodies  and  canal  systems ;  in 
the  lungs,  pseudo-sarcoma,  desquamation  of  the  epithelia, 
pneumonia  alba;  ...  in  the  central  nervous  system,  testicle 
and  epididymis,  similar  dififuse  perivascular  infiltrations  and 
hypoplasia  of  the  parenchyma"  (Hochsinger). 

The  placenta  usually  shows  changes  similar  to  those  in 
the  fetal  viscera.  Both  the  maternal  and  fetal  portions  of  the 
placenta  show  the  diffuse  perivascular  infiltration,  so  that  the 
placenta  is  more  voluminous  and  heavier  than  normal  (it  may 
reach  one  fourth  or  one  third  the  weight  of  the  child)  ;  the 
cord  is  also  hard  and  considerably  enlarged. 

The  distribution  of  spirochetse  in  these  various  lesions  has 
already  been  described.  Marked  changes  of  the  viscera  do 
not  appear  until  after  the  fourth  month  of  pregnancy. 

Symptoms. — The  fetus  affected  with  syphilitic  visceral 
lesions  may  come  to  one  of  three  ends,  as  follows : 

1.  It  may  be  aborted  or  stillborn. 

2.  It  may  be  born  manifestly  .syphilitic. 

3.  It  may  be  born  'apparently  healthy. 

I.  The  death  of  the  fetus  in  utero  is  often  caused  by 
hydramnia,  depending  upon  syphilitic  phlebitis  of  the  cord; 
or  by  inanition  from  overwhelming  visceral  disease.  Abor- 
tion usually  occurs  between  the  fourth  and  the  se\'enth  month, 
and  the  fetus  thus  aborted   is  usually   dead  and  macerated. 


5o8    HEREDITARY   SYPHILIS    IN    UTERO    AND    IN    INFANCY 

Monstrosities  are  said  to  be  relatively  frequent  in  syphilitic 
abortion  because  of  the  interference  with  placental  circulation. 
2.  The  typical  syphilitic  infant  presents  a  picture  of 
pseudo-senility — thin,  feeble,  marantic,  with  a  dull,  cafe  au 
lait  color,  a  wrinkled,  loose  skin,  upon  which,  even  at  birth, 
there  may  be  an  eruption ;  with  the  snuffles,  with  a  hoarse  cry, 


Fig.  62. — Congenital  Syphilis;  Wizened  Face:  Maculo-papular  Eruption 
WITH  Erosion  of  Lips  and  Large  Pustules  on  Brow:  Bilateral  In- 
TERSTiTLAi  Keratitis.     (Musee  St.  Louis.) 

with  sunken  and  inflamed  eyes,  and  perhaps  Avith  pseudo- 
paralysis or  some  lesion  of  the  nervous  system,  the  unfortu- 
nate infant  forms  a  horrible  picture  of  the  ravages  of  hered- 
itary syphilis  (Fig.  62). 

Among  the  whole  number  of  syphilitic  infants  relatively 
few  of  those  born  alive  present  so  marked  a  picture  of  disease. 
Not  only  may  the  infant  be  born  with  no  actual  syphilitic 
lesions  apparent,  but  he  may  be  in   fairly  good   condition. 


INFANTILE    SYPHILIS  509 

The  skin  is  likely  to  be  lacking  in  pinkness  and  fullness  and 
the  infant  rather  under  weight.  Thus  Tarnier,  among  52 
syphilitic  children,  found  14  of  normal  weight  (above  3,250 
gm.)   and  38  below  it  (Hochsinger). 

3.  But  the  child  with  syphilitic  lesions  of  the  viscera  may 
be  horn  seemingly  in  good  health.  Its  weight  may  be  ample, 
its  syphilitic  symptoms  nil,  its  viscera  and  bones  and  skin 
apparently  normal.  Yet  lesions  of  the  disease  develop  shortly 
after  birth,  and,  if  these  prove  fatal,  autopsy  reveals  extensive 
visceral  involvement. 

Jacquet  mentions  a  healthy  looking  child  "  on  whom  were 
found  two  or  three  dark-red  squamous  spots  on  the  knee, 
two  similar  ones  above  the  eyebrow,  and  very  slight  labial 
fissure — and  that  was  all;  but  the  infant  died  nevertheless, 
and  we  found  at  autopsy  abundant  specific  visceral  lesions  " 
(Berdal). 

The  direct  evidence  of  the  syphilitic  visceral  lesions  is  the 
enlargement  of  spleen  and  liver,  or  of  pseudo-paralysis  from 
osteochondritis. 

INFANTILE    SYPHILIS 

Although  the  lesions  presented  by  the  infant  with  hered- 
itary syphilis  are  due  to  precisely  the  same  protozoal  cause 
as  those  in  the  adult,  they  are  markedly  dissimilar.  Thus  we 
have  seen  that,  in  the  fetus,  the  viscera  are  the  chief  points 
of  attack.  In  the  infant  the  disease  first  strikes  the  mucous 
membrane  of  the  nose,  producing  snufiles,  and  then  shows 
itself  by  lesions  upon  the  skin;  but  these  skin  lesions  are  not 
the  same  in  character  as  those  of  early  syphilis  in  the  adult, 
nor  are  they  by  any  means  constant. 

Intermingled  with  these  symptoms,  or  succeeding  them, 
there  may  be  evidences  of  bone  or  visceral  disease,  or  the 
little  patient  may  show  his  malady  simply  by  his  thinness, 
his  slow  gain  in  weight,  and  his  restlessness. 


5IO    HEREDITARY   SYPHILIS    IN    UTERO    AND    IN    INFANCY 

Taking  up  the  early  symptoms  in  order  of  clinical  im- 
portance, we  shall  discuss : 

Inflammation  of  the  nose. 

Inflammation  of  the  skin. 

Inflammation  of  the  bones,  joints,  and  muscles. 

Inflammation  of  the  viscera. 

Mixed  "infection"    (pyogenic  or  tubercular). 

Syphilitic  dystrophies. 

INFLAMMATION    OF    THE    NOSE 

"  Snuflles  "  is  the  earliest  and  most  constant  symptom  of 
hereditary  syphilis,  and  one  of  the  least  characteristic.^  The 
symptom  is  not  quite  that  of  snuffles  in  an  older  child,  for  at 
first  there  is  little  or  no  running  from  the  nose,  but  only  an 
obstruction  to  nasal  respiration  which  makes  the  child  breathe 
in  a  characteristic  snuffly  way  and  gravely  interferes  with 
nursing. 

Hochsinger  has  tabulated  65  cases,  of  which  38  began 
at  birth,  15  in  the  first  month  and  12  later  than  the  first 
month. 

The  inflammation  begins  as  hypertrophy  of  the  nasal 
mucous  membrane,  at  first  a  dry  congestion  beginning  in  the 
lower  part  of  the  nose,  which  soon  goes  on  to  ulceration  and 
causes  a  profuse  mucous  discharge,  often  tinged  w^ith  blood; 
epistaxis  is  most  exceptional.  The  discharge  is  acrid,  and  ex- 
coriates the  upper  lip.  Perforation  of  the  septum  is  rare  in 
infancy;  but  as  a  result  of  this  coryza  the  development  of  the 
nasal  bones  is  impaired  or  arrested  and  the  bridge  of  the 
nose  left  sunken  in  a  characteristic  manner  (later  relapses  of 
hereditary  syphilis  of  the  nose  commonly  cause  perforation). 
Hence  result  the  various  nasal  deformities  so  suggestive  of 
syphilis. 

•  For  it  may  be  due  to  many  causes. 


INFLAMMATION    OF   THE    NOSE 


5" 


The  first  clinical  evidence  of  this  nasal  disease  is  restless- 
ness,  due  to  the  fact  that  the  little  patient's  sleep  is  constantly 
interfered  with  by  the  difficulty  of  breathing  through  its 
stopped-up  nose.  The  snuMy  breathing  soon  follows,  and  the 
infant,  being  unable  to  breathe  through  its  nose,  may  be  almost 
totally  unable  to  nurse;  its  attempts  at  suckling  and  swallow- 


FiG.  63.  —  Sunken  Nose  (en  Lorg- 
nette) FROM  Destruction  of  the 
Cartilage. 


Fig.   64.  —  Sunken  Nose   from  De- 
struction OF  THE  Bony  Septum. 


ing  being  frustrated  by  the  rapidly  recurring  need  of  breath- 
ing, so  that  the  process  becomes  a  disheartening  series  of 
gasps,  chokings,  and  regurgitations,  which  result  in  the  inges- 
tion of  little  or  no  nourishment.  Thus  this  relatively  insig- 
nificant lesion  may  be  the  chief  cause  of  a  grave  impairment 
of  nutrition. 


512     HEREDITARY   SYPHILIS   IN   UTERO   AND    IN    INFANCY 

INFLAMMATION    OF    THE    SKIN 

So  sensitive  is  the  skin  of  little  infants,  especially  if  they 
be  ill-nourished,  to  all  manner  of  irritative  eruptions,  and  so 
likely  are  the  syphilitic  skin  manifestations  to  appear  most 
markedly  upon  irritated  regions,  that  it  is  often  difficult  to 
distinguish  what  part  of  the  skin  lesion  is  wholly  syphilitic 
and  what  part  simply  irritative. 

Hence  the  striking  characteristics  of  the  first  skin  lesions 
of  hereditary  syphilis,  viz. : 

1.  Polymorphism. 

2.  Regional  distribution. 

3.  Confluence. 

The  Lesion. — The  first  secondary  lesion  to  appear  in 
acquired  syphilis  is  usually  the  general  macular  syphilid.  But 
in  hereditary  syphilis  the  first  (external)  lesion  to  appear  is 
usually  not  upon  the  skin  (but  in  the  nose),  and  when  the 
skin  lesions  do  appear  they  are  neither  generalized  nor  macu- 
lar. The  distribution  is  regional  (see  below),  the  lesion 
papulo-macular. 

The  papular  eruption  of  hereditary  syphilis  is  quite  com- 
parable to  that  of  acquired  syphilis  (page  287),  except  that 
it  is  commonly  intermingled  w^ith  lesions  of  a  macular  char- 
acter, and  is  itself  often  confluent. 

Most  of  the  lesions  are  papular  or  maculo-papular,  while 
an  occasional  macule  may  be  seen,  though  no  general  macular 
eruption  is  encountered. 

Polymorphism. — On  account  of  the  tenderness  of  the 
skin  this  papulo-macular  eruption  very  readily  takes  on  sec- 
ondary changes.  In  dry  regions  the  lesions  tend  to  become 
squamous,  or,  if  the  eruption  is  severe,  bullous  or  pustular;^ 

'  Jacquet  recognizes  a  special  type  of  syphilid,  the  acneiform;  it  is  quite  rare. 
The  lesion  is  a  very  small,  umbilicated  papule  covered  with  a  crust.  The 
eruption  tends  to  become  confluent  and  to  cover  large  areas. 


PEMPHIGUS  513 

while  in  moist  regions  the  lesions  are  often  confluent,  erosive, 
and  ulcerated. 

Regional  Distribution. — The  eruption  usually  appears 
about  the  genitals,  the  buttocks,  the  flexor  surfaces  of  the 
thighs,  upon  the  palms  and  soles,  and  upon  the  lips  and  chin. 
The  scalp,  arms,  and  legs  are  somewhat  less  frequently 
affected,  while  the  upper  part  of  the  trunk  above  the  line  of 
the  diaper  is  relatively  immune,  doubtless  because  it  is  the 
dryest  and  thickest  skin  upon  the  infant's  body. 

Confluence. — The  marked  tendency  to  confluence  shown 
by  the  early  skin  lesions  of  hereditary  syphilis  is  due  to  the 
tenderness  of  the  skin  and  the  difficulty  in  keeping  it  clean ; 
hence  the  confluent  lesions  are  usually  seen  under  the  diaper, 
in  various  moist  creases  of  the  body,  and  about  the  mouth. 

It  is  convenient  clinically  to  distinguish  five  types  of 
lesions : 

1.  Pemphigus. 

2.  Circumscribed  maculo-papular  syphilid. 

3.  Diffuse  maculo-papular  syphilid. 

4.  Lesions  of  special  regions. 

5.  Tubercular  or  gummatous  syphilid. 

e 

PEMPHIGUS 

The  earliest,  one  of  the  rarest,  and  the  most  ominous  skin 
lesion  of  hereditary  syphilis  is  pemphigus,  or  the  bullous 
syphilid.  It  appears  before  birth  or  in  the  first  week  of  extra- 
uterine life,  less  often  in  the  two  or  three  weeks  following. 
Its  typical  situation  is  upon  the  palms  and  soles,  whence  it 
may  spread  over  the  rest  of  the  body. 

The  eruption  consists  of  large,  copper-colored  papules, 
upon  which  are  set  flaccid  blebs  containing  serum  and  pus  or 
blood.  As  these  rupture  they  leave  an  eroded  surface;  or,  if 
the  ulceration  is  deep,  greenish  scabs  take  the  place  of  the 


514    HEREDITARY   SYPHILIS    IN    UTERO    AND    IN    INFANCY 

ruptured  bulte.  When  this  eruption  occurs  before  the  second 
week  of  extra-uterine  Hfe  it  is  an  accepted  sign  that  the  child 
will  die. 

Diagnosis. — It  may  be  readily  distinguished  from  the 
pemphigus  neonatorum,  which  never  occurs  before  the  second 
week,  and  usually  much  later,  is  often  epidemic,  occurs  upon 
otherwise  healthy  children,  and  only  most  exceptionally  ap- 
pears upon  the  palms  and  soles. 

CIRCUMSCRIBED    MACULO-PAPULAR    SYPHILID 

This  is  the  common  and  typical  eruption  of  early  hered- 
itary syphilis.  It  consists  of  rounded,  oval,  or  irregularly 
shaped  spots,  usually  a  dark  red  (though  sometimes  light) 
in  color.  Some  of  these  spots  are  macular,  others  papular, 
others  papulo-macular,  while  others  still  are  annular,  the 
periphery  of  the  affected  area  being  elevated  higher  than  its 
center;  in  diameter  they  average  i  cm.,  though  they  vary 
greatly.  Their  surface  is  tense,  with  a  satin  gloss,  and  may 
be  covered  with  little  scales  or  surrounded  by  a  scaly  collar. 

In  moist  creases  of  the  infant's  skin  the  papules  become 
eroded,  and  may  even  become  condylomatous ;  while,  wherever 
there  is  much  irritation  (especially  beneath  the  diaper  and 
about  the  mouth),  they  tend  to  run  together  and  to  ulcerate. 
Pustulation  is,  in  the  child  as  in  the  adult,  an  evil  omen. 

DIFFUSE    MACULO-PAPULAR    SYPHILID 

The  diffuse  maculo-papular  syphilid,  not  so  common  as 
the  circumscribed  form,  but  often  associated  with  it,  never 
begins  in  intra-uterine  life,  usually  appears  within  the  first 
three  months  after  birth,  and  may  relapse  during  the  first  year. 
It  occurs  most  frequently  beneath  the  diaper,  on  the  palms 
and  soles,  and  on  the  face.     It  has  the  characteristics  of  the 


DIFFUSE    MACULO-PAPULAR    SYPHILID 


515 


circumscribed  papular  eruption,  being  due  to  confluence  of  a 
number  of  smaller  papular  lesions.  When  it  occurs  under  the 
diaper  it  usually  stops  in  front  at  the  upper  part  of  the  thigh, 


Fig.  65. — Maculo-papular  Syphilid  in  Hereditary  Syphilis.     (Wilson.) 

and  extends  behind  over  the  flexor  surfaces  almost  to  the  knees; 
while  in  the  genital  creases  the  skin  is  broken  by  eroded,  ulcer- 
ated, or  condylomatous  areas. 
35 


5i6     HEREDITARY   SYPHILIS    IN    UTERO   AND    IN    INFANCY 

On  the  palms  and  soles  the  eruption  looks  thicker,  more 
tense  and  shiny,  and  yellowish.  Desquamation  of  large  patches 
of  thick  epidermis  is  common  here.  Upon  the  face  the  diffuse 
maculo-papular  syphilid  is  usually  confined  to  the  region  about 
the  mouth,  covering  the  upper  lip,  the  chin,  and  sometimes 
extending  down  on  to  the  neck. 


LESIONS   OF    SPECIAL   REGIONS 

Erosions  of  the  Lips. — Eroded  mucous  papules  are  very 
common  upon  the  vermilion  border  of  the  lips,  and  are  promptly 
fissured  and  transformed  into  deep-red,  oozing  cracks,  sur- 
rounded or  covered  by  a  little  crust.  They  are  usually  multiple, 
and  are  commonest  at  the  angle  of  the  mouth.  They  are 
extremely  painful,  and  interfere  gravely  with  suckling.  As 
they  heal  they  leave  marked  radiating  linear  scars  upon  the 
lips,  which  in  later  years  form  one  of  the  most  striking  and 
reliable  stigmata  of  hereditary  syphilis. 

Ano-genital  Lesions. — These  are  usually  associated  with 
dry  or  scaly  papules  elsewhere  in  the  body,  and  are  themselves 
confluent,  erosive,  or  ulcerated,  rarely  condylomatous,  and  still 
more  rarely  pustular.  But  in  the  relapses  of  early  childhood 
condylomata  are  very  common. 

Onychia  and  Paronychia. — The  typical  nail  of  the  syphi- 
litic infant  is  raised  high  in  the  center  and  depressed  laterally, 
as  though  it  had  been  pinched  by  a  forceps  (Holt).  It  resem- 
bles a  claw  rather  than  a  nail.  This  clawlike  nail  is  quite 
common,  and  strongly  suggestive  of  syphilis.  The  condition 
usually  affects  all  the  nails. 

Such  nails  are  often  undermined  by  a  species  of  paronychia, 
so  that  they  are  readily  detached. 

Lesions  of  the  Scalp. — Inasmuch  as  the  infant  loses  its 
first  hair  a  few  days  after  birth,  one  cannot  say  that  syphilitic 
defluvium  at  this  time  is  common.     Certainly  the  moth-eaten 


LESIONS    OF    MUCOUS    MEMBRANE  517 

poll  is  quite  uncommon  in  infancy,  and  more  extensive  bald- 
ness (which  has  the  same  characteristics  as  in  the  adult)  very 
rare. 

The  papular  eruption  upon  the  scalp,  instead  of  forming 
small,  disseminated,  crusted  lesions,  as  in  the  adult,  may  pro- 
duce an  extensive  incrustation  closely  simulating  eczema;  but 
the  syphilitic  lesion  is  distinguished  by  the  fact  that  removal 
of  the  scabs  leaves  an  intact,  though  infiltrated  area  beneath  it, 
while  removal  of  an  eczematous  crust  leaves  the  Malpighian 
rete  exposed. 

TUBERCULAR   AND    GUMMATOUS   SYPHILID 

It  is  not  always  possible  to  distinguish  between  a  furuncle 
and  a  syphilitic  tubercle  or  gumma;  indeed,  these  lesions  are 
classed  as  "  furuncular  syphilids  "  by  Taylor,  while  their  syphi- 
litic nature  is  entirely  denied  by  Jacquet;  they  are,  however, 
accepted  by  most  authorities,  and  Carpenter  ^  states  that  among 
364  syphilitic  eruptions  seen  by  him  during  the  first  year  of 
life  there  were  70  cutaneous  gummata,  34  of  which  were  asso- 
ciated with  other  lesions  of  the  skin. 

Among  these  70  cases,  4  occurred  in  the  first  month,  21  in 
the  second  and  third,  14  in  the  fourth  and  fifth,  11  in  the  sixth 
and  seventh,  and  only  15  in  the  remaining  five  months.  The 
lesions  are  those  of  syphilitic  tubercle  and  subcutaneous  gum- 
ma; but  they  have  an  especial  tendency  to  become  pustular, 
and  so  remain  for  a  considerable  time  before  ulcerating.  They 
come  out  in  successive  crops,  and  disappear  under  mercurial 
treatment. 

LESIONS   OF   MUCOUS   MEMBRANE 

Excepting  the  nose,  the  lips,  and  the  anus,  lesions  of  the 
mucous  membrane  are  extremely  rare.     The  ulcers  that  occur 

'  "The  Syphilis  of  Children,"  London,  1901. 


5i8     HEREDITARY    SYPHILIS    IN    UTERO    AND    IN    INFANCY 

in  the  mouth  are  alleged  by  many  authors  to  be  aphthous,  not 
triily  syphilitic. 

Aphonia  is  frequent,  however,  and  is  apparently  due  to 
infiltrative  and  ulcerative  laryngeal  lesions  similar  to  those  seen 
in  the  adult.  The  familiar  "  hoarse  cry  "  of  the  syphilitic 
infant  is  quite  as  suggestive  and  far  more  common  than  the 
hoarse  voice  of  the  syphilitic  adult. 

The  intestine  may  be  inflamed,  and  may  show  post  mortem 
a  diffuse  thickening  of  the  mucous  membrane  with  ulceration. 


INFLAMMATION  OF   THE   BONES,  THE   JOINTS, 
AND   THE   MUSCLES 

While  any  of  the  lesions  of  bone  that  occur  in  the  adult 
may  also  occur  in  hereditary  syphilis,  the  two  striking  and 
distinctive  characteristics  of  bone  syphilis  in  the  infant  are 
osteochondritis  and  periostitis. 

The  former  begins  before  birth,  the  latter  shortly  after 
birth ;  a  difference  explained  by  Hochsinger  as  due  to  the  fact 
that  syphilis  attacks  the  most  actively  functionating  region, 
which  is  the  epiph3^seal  junction  in  intra-uterine  life  and  the 
periosteum  thereafter.  Both  types  are  in  their  milder  mani- 
festations extremely  common. 

Osteochondritis. — Mild  syphilitic  osteochondritis,  causing 
slight  distortion  and  enlargement  of  the  bone  at  the  epiphyseal 
line,  is  very  common.  Its  lesions  can  be  accurately  studied 
only  by  the  X-ray. 

The  knee  and  the  elbow  are  most  commonly  and  most 
markedly  affected ;  and  the  lesion  consists  in  a  syphilitic  infil- 
tration of  the  diaphysis  at  its  junction  with  the  epiphysis, 
which  results  in  a  thickening  of  thq  bone  at  this  point  and  a 
marked  irregularity  at  this  line  of  junction,  as  is  well  shown 
by  the  accompanying  radiograph  (Fig.  66).  Very  rarely  this 
lesion  progresses  so  far  that  the  granulomatous  tissue,  disin- 


INFLAMMATION    OF    THE    BONES,    ETC. 


519 


tegrating  the  epiphyseal  cartilage,  produces  an  epiphyseolysis. 
This  rare  lesion,  appropriately  called  "  syphilitic  pseudo-paral- 


FlG.    66. — OSTEO-CHONDRITIS    (PSEUDO-PARALYSIs)    OF    BOTH    KNEES.       Notc    the 

marked  thickening  and  irregularity  of  the  lower  ends  of  the  femoral  and  upper 
ends  of  the  tibial  diaphyses  (compare  normal  knee  in  Fig.  56).  (Case  of  Dr. 
La  Fetra.     Skiagraph  by  Dr.  Caldwell.) 

ysis  of  the  newborn,"  usually  affects  the  elbow  and  is  congen- 
ital ;  it  may  be  polyarticular. 

"  Its  essential  character  is  an  inertia,  an  impotence  of  the 


520     HEREDITARY    SYPHILIS    IN    UTERO    AND    IN    INFANCY 

limbs,  which  may  be  partial  or  general,  incomplete  or  abso- 
lute. .  .  .  For  an  accurate  study  of  the  state  of  the  child  and 
of  the  degree  of  its  disability,  it  must  be  held  up  by  the  axillae 
while  its  limbs  are  being  examined.  When  the  affection  is 
marked  the  child's  limbs  seem  dislocated  and  hang  like  bell- 
clappers,  limp  and  inert.  Pinch  the  skin  and  the  infant's  mus- 
cles contract  sharply,  but  its  limbs  are  little  moved  by  this  con- 
traction ;  yet  they  offer  no  resistance  to  any  movement  imparted 
to  them  by  the  observer.  .  .  .  Sometimes  one  feels  crepitation, 
and  in  certain  infants  the  limbs  are  increased  in  size  in  the 
region  of  the  joints;  fluctuation  may  even  be  made  out  "  (Par- 
rott). 

This  epiphyseolysis  occurs  only  when  there  is  marked  vis- 
ceral disease,  and  is  an  evil  omen. 

Periostitis. — The  periosteal  lesions  of  early  syphilis  are 
usually  most  marked  upon  the  skull,  though  similar  lesions 
may  affect  any  bone. 

The  lesions  of  syphilis  in  the  skull  are,  in  order  of  fre- 
quency— infiltration  and  softening  betM^een  the  tables  and  in 
the  sutures ;  diffuse  periostitis  of  the  frontal  or  parietal  bosses, 
causing  an  enlargement  which,  if  frontal,  produces  the  so-called 
"  Olympian  "  brow ;  if  lateral,  a  considerable  widening  of  the 
transverse  diameter  of  the  skull  (natiform  skull).  Less  fre- 
quent is  the  rarefying  ostitis  with  tendency  to  gummatous 
degeneration.  Finally,  the  skull  may  be  affected  secondarily 
by  hydrocephalus. 

American  authorities  consider  it  unsafe  to  accept  cranial 
deformities  as  evidence  of  hereditary  syphilis  unless  supported 
by  other  typical  signs.  Parrott's  nodes  and  cranio-tabes, 
though  sometimes  spoken  of  as  syphilitic,  are  actually  of 
rachitic  origin. 

Dactylitis. — The  dactylitis  previously  described  (page 
441)  is  far  more  common  in  hereditary  than  in  acquired 
syphilis. 


INFLAMMATION    OF    THE    VISCERA  521 

Ribs. — Circumscribed  nodes  are  said  by  Hochsinger  to  be 
common  in  the  lateral  thoracic  region  at  the  level  of  the  fourth 
or  the  fifth  rib. 

Arthritis.^ At  this  early  age  the  joints  are  very  rarely 
involved,  except  as  a  complication  of  severe  osteochon- 
dritis. 

Myositis. — Syphilitic  inflammation  of  the  muscles  usually 
affects  the  biceps  or  the  sterno-mastoid,  originates  in  periostitis, 
and  causes  a  fixed  cramp  of  the  muscle  (cf.  page  448).  Hoch- 
singer states  that  the  so-called  muscle  gummata  are  usually 
hematomata. 

INFLAMMATION    OF    THE    VISCERA 

Lymph  Nodes. — Lymphadenitis  is  not  typical  of  hereditary 
syphilis.  It  is  common  when  there  is  a  multiplicity  of  syphilitic 
lesions;  marked  epitrochlear  adenitis  is  of  some  diagnostic  im- 
portance. The  presence  of  other  enlarged  nodes  is,  as  a  rule, 
directly  attributable  to  adjacent  lesions. 

Testicle. — Syphilitic  sclerosis  of  the  testicle  is  extremely 
common  in  stillborn  children.     It  is  rare  in  those  that  survive. 

Inasmuch  as  the  size  of  the  testicle  in  infancy  varies  be- 
tween wide  limits  while  syphilis  of  the  organ  often  does  not 
greatly  alter  its  size,  the  clinical  manifestation  of  the  lesion 
is  usually  an  increase  in  hardness,  which  may  be  masked 
by  hydrocele.  Testis  and  epididymis  may  be  involved  sepa- 
rately or  together.  The  lesion  may  be  unilateral  or  bilateral. 
Hydrocele  is  quite  common ;  fungus  is  rare.  The  lesion  may 
pass  undiscovered.  It  usually  kads  to  atrophy  of  the  testicle, 
and  great  stress  is  laid  by  certain  authors  upon  the  existence 
of  this  atrophy  in  adult  years  as  an  evidence  of  hereditary 
syphilis. 

Diagnosis. — Inasmuch  as  tuberculosis  of  the  testicle  may 
occur  shortly  after  birth  (Dreschfield  has  recorded  a  congenital 
case),  and  produce  lesions  macroscopically  similar  to  those  of 


522 


HEREDITARY   SYPHILIS    IN    UTERO    AND    IN    INFANCY 


syphilis,  the  diagnosis  is  not  always  possible;  but  of  the  two 
diseases  syphilis  is  by  far  the  more  common. 

Liver  and  Spleen. — Hereditary  syphilis  of  the  liver  and 
spleen  are  so  intimately  associated  that  it  seems  proper  to 
consider  them  as  one.  Syphilitic  changes  may  be  found 
in  these  organs  in  many  instances  post  mortem,  although 
no  evidence  of  such  disease  was  apparent  during  life.  The 
pathological  changes  have  already  been  described  (pages  470, 
506). 

Clinically,  the  manifestation  of  these  lesions  consists  in  an 
enlargement  of  the  affected  organs.  This  enlargement  is  noted 
in  thirty  per  cent  to  forty  per  cent  of  cases  in  the  first  three 
months  of  life;  and  in  almost  every  instance  enlargement  of  the 
spleen  implies  enlargement  of  the  liver,  and  vice  versa}  The 
enlargement,  though  usually  slight,  may  be  considerable,  and, 
exceptionally,  one  may  identify  thickening  of  the  edge  and 
irregularity  of  the  outline  of  the  liver,  as  in  acquired  syphilis. 
Syphilitic  jaundice  is  extremely  rare  in  early  infancy.  Ascites 
does  not  occur  until  a  later  age. 

Lungs. — The  pathology  of  pulmonary  syphilis  has  been 
described  elsewhere  (page  462).  These  lesions  are  so  com- 
monly fatal  that  they  can  scarcely  be  said  to  give  any  clinical 
manifestations. 

Nervous  System. — Restlessness  and  sleeplessness  are  strik- 
ing symptoms  of  early  hereditary  syphilis,  and  have  been  re- 
ferred to  meningeal  irritation,  but  are  more  probably  due  to 
nasal  obstruction.  Though  these  early  cases  may  show  post- 
mortem lesions  throughout  the  nervous  system,  they  show 
during  life  no  evidence  of  peripheral  neuritis  or  of  syphilis 

>  Hochsinger  found  that  splenic  enlargement  accompanied  hepatic  en- 
largement in  forty -four  out  of  forty -six  cases.  He  also  states  that  only  three  per 
cent  infants  showing  enlargement  of  the  spleen  were  not  syphilitic.  Carpenter 
states  that  when  the  spleen  is  enlarged  the  liver  is  also  enlarged  in  four  fifths 
of  the  cases. 


MIXED    INFECTION  523 

of  the  cord;  while  symptoms  of  syphiHtic  meningitis  other 
than  restlessness,  sleeplessness,  and  convulsions  are  extremely 
rare.  The  only  exception  is  hydrocephalus.  This,  whether 
acute  or  chronic,  internal  or  external,  is  often  syphilitic, 
and  develops  with  the  first  outbreak  of  symptoms  (in  the 
first  or  second  month).  So  common  is  this  association  of 
hydrocephalus  and  syphilis,  and  so  hopeless  is  the  former 
condition  when  not  syphilitic,  that  it  is  most  excellent  practice 
to  treat  every  infant  with  hydrocephalus  as  though  it  were 
syphilitic. 

Eye. — Lesions  of  the  eye  are  extremely  rare  at  this  early 
date.  Iritis,  parenchymatous  keratitis,  and  optic  neuritis  have 
been  noted,  while  it  is  highly  probable  that  many  cases  of 
choroiditis  begin  very  early  in  life. 

Ear. — Extension  of  the  nasal  catarrh  to  the  middle  ear, 
resulting  in  acute  otitis  media,  is  not  uncommon.  Paralysis 
of  the  nerve  or  inflammation  of  the  labyrinth  usually  occurs 
at  a  later  date. 

MIXED    INFECTION 

As  a  frequent  and  grave  complication  of  early  hereditary 
syphilis  it  shows  itself  chiefly  in  four  types : 

1.  Mixed  infection  of  the  skin. 

2.  Mixed  infection  of  the  respiratory  tract. 

3.  Mixed  infection  of  septic  type. 

4.  Tuberculosis  and  rachitis. 

Skin. — Mixed  infection  of  the  skin  shows  itself  in  the  fre- 
quency of  pustular  and  ulcerating  lesions,  while  pseudo-furun- 
culosis  is  due  in  most  instances  to  pyogenic  bacteria. 

Respiratory  Tract. — The  discharges  of  syphilitic  coryza 
swarm  with  spirochet?e  and  with  all  manner  of  bacteria.  Hence 
the  inflammation  may  spread  to  the  ear,  causing  otitis  media, 
or  to  the  lung,  causing  broncho-pneumonia.  This  latter  com- 
plication accounts  for  many  deaths. 


524    HEREDITARY    SYPHILIS    IN    UTERO    AND    IN    INFANCY 

Sepsis. — The  petechise  and  other  hemorrhagic  skin  lesions 
that  occur  in  certain  mahgnant  cases  of  early  hereditary  syphi- 
lis are,  doubtless,  evidences  of  acute  septicemia. 

Tuberculosis  and  Rachitis. — The  relation  between  rachitis 
and  syphilis  has  long  since  been  determined.  Parrott  believed 
and  taught  that  every  rachitic  child  was  syphilitic;  but  subse- 
quent investigation  has  clearly  shown  that  this  is  not  the  case, 
that  syphilis  is  only  one  among  many  potential,  debilitating 
causes  of  rickets. 

The  same  is  true  of  tuberculosis.  Sergent  ^  has  recently 
collected  much  evidence  in  the  matter,  and,  with  a  wealth  of 
authoritative  quotations,  enforces  his  conclusions  that  "  la  S3^ph- 
ilisation  du  pere  a  prepare  le  terrain  pour  la  tuberculisation  du 
fils  " — syphilis  in  the  father  prepares  the  soil  for  tuberculosis 
in  the  son." 

This  aphoristic  statement  expresses  the  actual  condition 
not  quite  accurately.  It  is  necessary  to  distinguish  as  fol- 
lows : 

1.  Syphilis  in  the  father,  if  severe  or  if  allied  with  other 
debilitating  influences,  such  as  drink,  deprivation,  or  debauch, 
prepares  the  father's  own  soil  for  tuberculosis. 

2.  Syphilis  transmitted  from  parent  to  child — hereditary 
syphilis — exercises  the  same  predisposing  influence  magnified 
b_y  the  difficulty  of  eradicating  the  disease  from  the  vulnerable 
tissues  of  the  newborn. 

3.  But  the  non-syphilitic  child  of  a  S3^philitic  parent  is  not 
predisposed  to  tuberculosis,  unless  by  such  privation  or  neglect 
as  would  so  predispose  it  in  any  event. 

Although  tuberculosis  and  rachitis  are  frequently  attendant 
upon  syphilis  a  little  later  in  life,  they  scarcely  figure  in  the 
first  few  months. 

•  "Syphilis  et  tuberculose,"  Paris,  1907. 


SYPHILITIC    DYSTROPHIES  525 

SYPHILITIC    DYSTROPHIES 

The  interference  with  nutrition  due  to  hereditary  syphihs 
shows  itself  in  two  ways :  First,  and  most  frequently,  by  kill- 
ing the  child  within  a  few  days  of  its  birth ;  secondly,  by  im- 
pairing its  nutrition,  but  not  killing  it. 

The  first  evidence  of  impaired  nutrition  may  be  the  puny, 
decrepit  state  of  the  child  at  birth;  or  the  child  may  be  born 
apparently  healthy,  and  promptly  lose  weight  and  strength  in 
spite  of  a  good  digestion  and  an  abundant  supply  of  mother's 
milk.  Such  infants,  though  they  may  survive  for  a  time,  are 
carried  of¥  either  by  the  cachexia  of  the  disease  itself  or  by  such 
complications  as  convulsions,  diarrhea,  or  broncho-pneumonia 
during  the  first  year  of  their  lives. 

From  these  various  causes  something  like  nine  out  of  ten 
bottle-fed  or  hospital  babies  fail  to  survive,  though  in  private 
practice  hygiene,  human  milk,  and  intelligent  medical  care  cut 
down  the  mortality  considerably. 

But  beyond  this  obviously  syphilitic  toxemia  there  is  a  set 
of  vague  conditions,  such  as  go  to  produce  congenital  deform- 
ities, e.  g.,  club-foot,  harelip,  etc.,  or  to  arrest  development 
causing  the  child  to  attain  puberty  very  late,  to  have  its  sex 
characteristics  ,but  slightly  developed,  and  to  remain  childish 
both  in  mind  and  body.  Idiocy  and  epilepsy  are  said  to  be 
exceptionally  frequent  in  otherwise  apparently  healthy  children 
of  syphilitic  parents. 

In  how  much  these  conditions  are  due  to  a  real  S3q3hilis 
of  the  child  and  in  how  much  to  an  inherited  tendency  from 
the  parent  (similar  to  that  of  alcoholism,  for  instance)  it  is 
difficult  to  say;  but  it  is  perhaps  safer  to  assume  that  in  most 
instances  the  child  is  actually  syphilitic,  and  does  harbor  or  has 
harbored  the  spirocheta.  For  there  seems  no  adequate  reason 
to  suppose  that  syphilis  of  the  parent,  unless  it  is  gravely  im- 
pairing the  parent's  own  nutrition,  should  have  any  very  obvi- 


526     HEREDITARY   SYPHILIS    IN    UTERO    AND    IN    INFANCY 

ous  effect  upon  the  nutrition  of  the  sperm  cell  and  of  the  infant. 
It  would  seem  quite  probable,  however,  that  many  cases  of 
impaired  nutrition  attributed  to  syphilis  should  be  attributed 
to  a  concomitant  parental  alcoholism  or  to  other  deteriorating 
forces. 


CHAPTER    XXXVI 

HEREDITARY  SYPHILIS;  RELAPSES;  LATE   LESIONS; 
DIAGNOSIS;  PROGNOSIS;   TREATMENT' 

RELAPSES    IN    EARLY    CHILDHOOD 

After  the  first  outbreak  of  hereditary  syphiHs  in  the  first 
three  months  of  the  disease  the  affection  may  remain  in  abey- 
ance or  may  relapse.  Relapses  are  peculiarly  liable  to  occur 
in  the  first  and  second  year  of  life,  also  from  the  sixth  to  the 
eighth  year,  and  from  the  time  of  puberty  until  the  twenty- 
fifth  year.  These  periods  are,  of  course,  vagiie  and  undefined. 
There  may  be  no  intervals  between  relapses  and  there  may  be 
years. 

Relapses  of  early  childhood  commonly  occur  in  the  first 
two  years,  but  may  continue  for  several  years  longer.  In 
these  relapses  the  skin  manifestations,  while  remaining  the  same 
as  those  already  described,  are  likely  to  be  less  diffuse,  less 
polymorphous,  and  rather  more  tertiary  in  type  ;  copper  colored, 
or  tubercular,  or  furuncular.  Condylamata,  however,  remain 
frequent — even  more  frequent  than  during  the  first  outbreak. 

Of  the  lesions  of  the  nervous  system,  hemiplegia  and  epi- 
lepsy are  the  most  important,  while  chorio-retinitis  and  optic 
neuritis  are  quite  common.- 

1  Reviewed  by  Dr.  John  Howland. 

2  Among  the  visceral  manifestations  which  Hochsinger  mentions  are  the 
stridor  thymicus  caused  by  pressure  of  the  enlarged  thymus  on  the  trachea, 
paroxysmal  hemoglobinuria,  hematoporphyriuria;  and  as  a  result  of  splenic 
syphilis,  the  anemia  pseudo-leukemia  infantum;  this  occurs  at  the  end  of  the 
first  and  during  the  second  year. 

527 


528 


HEREDITARY    SYPHILIS 


But  the  important  feature  of  this  period  is  the  confusion  of 
rachitis  and  syphilis.  For,  inasmuch  as  rachitis  does  not  show 
itself  until  after  the  child  is  three  months  old,  the  splenic  en- 
largement and  bone  deformity  of  early  syphilis  do  not  lend  any 
color  to  the  theory  of  rachitis  until  the  first  three  months  have 
passed.  But  since  an  enlarged  spleen,  manifest  malnutrition, 
and  very  similar  bone  lesions  may  be  the  only  manifestations  of. 
either  disease,  it  is  small  wonder  that  they  should  be  confused 
with  each  other.  Indeed,  in  certain  cases  it  may  be  impossible 
to  decide  whether  the  child  is  syphilitic  or  rachitic,  or  both 
syphilitic  and  rachitic,  if  its  first  outbreak  of  syphilitic  symp- 
toms has  been  so  slight  as  to  be  overlooked  (page  537). 

LATE    HEREDITARY   SYPHILIS 

From  the  sixth  to  the  eighth  year,  and  again  at  about  the 
time  of  puberty,  hereditary  syphilis  may  relapse;  relapses  ex- 
cepting at  these  times  are  infrequent. 

The  limit  of  duration  of  hereditary  syphilis  is  quite  as  in- 
definite as  that  of  acquired  syphilis.  It  may  surely  last  through- 
out the  patient's  lifetime,  though  after  adult  life  is  reached  its 
lesions  are  extremely  rare,  and  it  may  be  clinically  impossible 
to  say  whether  these  lesions  are  due  to  a  hereditary  or  to  an 
acquired  disease. 

The  arbitrary  limit  of  twenty-six  years  set  by  Fournier  for 
the  duration  of  hereditary  syphilis  is,  in  general,  the  extreme 
limit ;  indeed,  lesions  after  puberty  are  extremely  rare.  Whether 
late  hereditary  syphilis  may  occur  in  an  infant  who  has  shown 
no  early  manifestations  of  the  disease  has  long  been  a  matter  of 
controversy ;  and  the  question  will  never  perhaps  be  more  sat- 
isfactorily answered  than  by  the  statement  that  children  show- 
ing lesions  of  late  hereditary  syphilis  usually  give  a  history  of 
snuffles  and  of  lesions  in  childhood ;  but  yet  this  history  may 
be  wanting.     Whether,  in  such  event,  the  early  symptoms  are 


LATE    HEREDITARY    SYPHILIS  529 

actually  skipped  or  simply  overlooked,  it  is  not  possible  to 
state.  The  former  hypothesis  is  possible,  but  the  latter  is  far 
more  probable. 

There  is  no  more  call  to  make  a  special  class  of  those  cases 
of  late  hereditary  syphilis  that  give  no  history  and  show  no 
evidence  of  early  lesions  than  there  would  be  to  make  a  like 
distinction  in  acquired  syphilis.    • 

The  active  syphilitic  lesions  of  late  hereditary  syphilis  are, 
with  but  very  few  exceptions,  quite  the  same  as  those  that 
occur  in  late  acquired  syphilis.  They  are,  in  other  words,  the 
tertiary  lesions  of  the  disease  occasionally  intermingled,  as  in 
acquired  syphilis,  with  certain  late  secondaries,  especially  those 
of  the  palms,  the  soles,  and  the  tongue.  Certain  classes  of 
lesions  are,  however,  somewhat  more  common  in  late  heredi- 
tary than  in  late  acquired  syphilis.  Such  are  the  various 
lesions  of  the  eye,  deafness  from  internal  ear  disease,  perfora- 
tion of  the  septum  and  palate,  and  diffuse  periostitis  of  the 
long  bones.  The  joints  are  relatively  often  affected,  and  the 
danger  of  mistaking  a  pseudo-tubercular  syphilitic  knee  in 
the  young  for  the  tubercular  "  white  swelling  "  must  be  borne 
in  mind. 

The  chief  exceptions  in  which  late  hereditary  syphilis  dif- 
fers from  late  acquired  syphilis  are  diffuse  periostitis  and 
parenchymatous  keratitis.  Besides  these  two  lesions  there  are, 
however,  many  stigmata  of  early  hereditary  lesions,  which 
will  be  taken  up  in  the  following  section. 

Diffuse  Periostitis. — The  periosteal  changes  of  late  hered- 
itary syphilis  are  the  same  as  those  of  accjuired  syphilis  except- 
ing in  their  distribution.  The  hereditary  lesions,  are,  however, 
often  much  more  diffuse  than  the  acquired  ones,  sometimes 
extending  over  the  whole  length  of  a  long  bone.  This  diffuse 
process  is  most  common  in  the  tibia,  to  which  it  imparts  a 
peculiar  and  pathognomonic  form.  The  shaft  of  the  bone  is 
thickened  in  all  its  diameter^,  but  especially  antero-posteriorly ; 


530 


HEREDITARY   SYPHILIS 


SO  that,  at  first  glance,  the  bone  appears  to  be  bowed  forward ; 
but  palpation  reveals  that  this  bowing  is  simply  a  thickening 
around  it  of  new  bone  without  any  deviation  in  the  axis  of 


Fig.  67. — Saber  Tibia  (Diagrammatic). 

the  bone  itself    (in  marked  contrast  to   the  bowed   shins   of 
rickets). 

The  new  bone  is  fairly  smooth,  perfectly  dense  and  insen- 
sitive, and  so  ensheathes  the  original  bone  as  to  completely  con- 
ceal it.     The  anterior  edge  of  the  tibia  is  markedly  rounded. 


LATE    HEREDITARY    SYPHILIS  531 

Its  epiphyses,  especially  the  upper  one,  may  also  be  enlarged ; 
and  if  there  has  been  early  disease  at  the  epiphyseal  junction, 
the  limb  may  be  shortened  by  premature  ossification,  or  length- 
ened by  excessive  ossification.  This  bowed  tibia  is  appropri- 
ately termed  the  "  saber-blade  "  tibia  (Figs.  54,  67)  ;  it  is  abso- 
lutely pathognomonic  of  syphilis. 

Parenchymatous  Keratitis. — Parenchymatous  keratitis, 
though  it  may  occur  in  the  first  months  of  extra-uterine  life 
or  even  before  birth  (Parinaud),  and  as  late  as  the  thirty- 
sixth  year  (Huguenin),  is  common  only  between  the  eighth 
and  the  fifteenth  year  (Hutchinson).  It  is  one  of  the  fre- 
quent manifestations  of  hereditary  syphilis,  occurring  very  fre- 
quently (fifty-nine  per  cent,  according  to  Huguenin).  On  the 
other  hand^  it  is  by  no  means  pathognomonic  of  syphilis. 
Though  Hutchinson  places  great  weight  upon  it  as  a  diagnos- 
tic sign,  careful  investigation  reveals  other  evidences  of  syphi- 
lis in  not  much  more  than  one  half  the  cases  (thirty-six  per 
cent,  according  to  Alexander;  fifty-five  per  cent,  according  to 
Michel).  Hence  it  is  not  of  itself  an  absolute  proof  of  the 
existence  of  syphilis. 

Moreover,  interstitial  keratitis  may  occur  in  acquired  syphi- 
lis.    My  father  has  seen  two  instances  of  this. 

The  lesion  is  almost  always  bilateral,  although  it  begins 
first  in  one  eye.  It  begins  painlessly  with  a  diffuse  opacity 
(usually)  in  the  center  of  the  cornea.  This  opacity  gradually 
increases  in  size^  but  does  not  ulcerate;  and  pericorneal  con- 
gestion soon  appears. 

After  some  three  weeks  the  whole  cornea  has  become  in- 
volved and  looks  like  a  piece  of  ground  glass.  The  pericor- 
neal injection  has  markedly  increased,  and  the  cornea  itself 
may  be  so  congested  as  to  assume  a  pinkish  hue.  This  is  often 
the  first  sign  of  beginning  resolution. 

After  six  weeks  or  so  from  the  beginning  of  the  trouble 
the  whole  process  begins  to  diminish.  The  congestion  disap- 
36 


532 


HEREDITARY    SYPHILIS 


pears  and  the  opacity  is  more  or  less  resolved.  It  very  rarely 
disappears  completely,  but  usually  leaves  a  disfiguring  central 
scar  large  enough  to  impair  if  not  to  destroy  vision. 

The  subjective  symptoms  are  photophobia  and  obstruc- 
tion of  vision.  The  permanency  of  this  obstruction  cannot 
be  foretold;  but  if  a  central  scar  remains  it  is,  of  course, 
permanent. 

Such  complications  as  iridokeratitis  and  opacities  of  the  lens 
or  other  adhesions  are  fairly  frequent. 

Glaucomatous  complications  are  rare. 

Treatment. — The  local  treatment  consists  in  protecting 
the  eyes  by  smoked  glasses  and  the  iris  by  instillations  of 
atropin  (page  415). 

Mercurial  treatment  should  be  given,  though  it  is  by  no 
means  proven  that  this  has  any  beneficial  effect.  The  tension 
of  the  eye  must  be  carefully  observed  lest  glaucoma  intervene. 

The  application  of  hot  compresses  to  the  eye  for  a  half 
hour  (renewing  them  every  two  or  three  minutes),  five  or  six 
times  a  day,  is  said  to  encourage  healing. 

STIGMATA    OF    HEREDITARY    SYPHILIS 

The  stigmata  of  hereditary  syphilis  are  the  scars  of  syphi- 
litic lesions  or  the  deformities  or  peculiarities  in  development 
left  by  syphilitic  lesions  occurring  in  infancy  or  in  youth.  They 
are  more  or  less  pathognomonic  of  the  disease,  though  few  of 
them  (only  the  radiating  fissures  of  the  lips  and  the  typical 
saber  tibia)  are  absolutely  so.  Yet  many  of  them  are  presump- 
tive evidence  of  the  greatest  importance. 

Only  these  important  stigmata  need  be  described.  Other 
developmental  defects  indirectly  due  to  syphilis,  such  as  rickets. 
idiocy,  cleft  palate,  club-foot,  etc.,  may  be  excited  by  so  many 
other  causes,  known  or  unknown,  that  though  we  may  in  spe- 
cific instances  acknowledge  their  derivation  from  syphilis,  we 


STIGMATA    OF    HEREDITARY    SYPHILIS  533 

may  not  infer  from  them  that  the  patient  is  syphilitic,  i.  e., 
their  importance  as  syphihtic  stigiiiata  is  neghgible. 

Moreover,  it  is  to  be  noted  that  most  of  these  stigmata  are 
only  evidence  that  the  patient  has  had  S3qDhilis  in  childhood  or 
in  infancy;  whether  acquired  or  hereditary  they  do  not  decide. 
Yet  certain  of  them  (especially  the  lip  fissures  and  the  dental 
deformities)  derive  from  lesions  of  so  early  a  date  that  they 
point  to  an  hereditary  taint  with  almost  absolute  certainty. 

The  chief  stigmata  of  hereditary  syphilis  may  be  classed 
as  follows : 

1.  Hutchinson's  triad,  consisting  of  dental,  ocular,  and 
auditory  stigmata. 

2.  Bone  stigmata. 

3.  Skin  stigmata. 

4.  Visceral  stigmata. 

5.  Constitutional  stigmata. 

Of  these,  the  first  three  are  of  prime  importance,  the  two 
last  are  rarer  and  less  characteristic. 

Excepting  Hutchinson's  triad,  these  stigmata  have  already 
been  described  in  connection  with  the  lesions  that  cause  them. 
The  chief  bone  stigmata  are  found  in  the  skull  (frontal  or  lat- 
eral bosses,  asymmetry  and  irregular  development,  hydroceph- 
alus), in  the  nose  (sunken  bridge),  and  in  the  long  bones  (dif- 
fuse periostitis,  saber  tibia,  and  such  scars  of  epiphyseitis  as 
epiphyseal  enlargements,  and  arrested  or  excessive  growth  of 
the  bone).  The  skin  stigmata  do  not  differ  from  those  of 
acquired  syphilis,  excepting  the  important  lip  fissures.  The 
only  notable  visceral  stigma  is  atrophy  of  the  testicle.  The 
constitutional  stigmata  consist  of  a  gray  bloodless  s^in  and 
a  slowness  of  physical  and  intellectual  development  that  may 
amount  to  "  infantilism  "  or  idiocy  (page  525). 


534  HEREDITARY    SYPHILIS 


HUTCHINSON'S   TRIAD 

Most  important  among  the  stigmata  of  hereditary  syphi- 
lis are  those  lesions  grouped  as  a  triad  by  Jonathan  Hutchin- 
son, Sr.,  from  whom  they  very  appropriately  derive  their  title. 

"  Hutchinson's  triad  "  is  commonly  taken  to  mean  the  asso- 
ciation of — 

1.  Notched  and  pegged  upper,  central,  permanent  incisors. 

2.  Interstitial  keratitis  or  the  scar  thereof,  and 

3.  Nerve  deafness. 

But  though  these  three  are  the  most  striking  of  the  lesions 
in  question,  it  is  preferable  to  employ  the  term  in  a  looser  sense 
to  cover  all. 

1.  Dental  stigmata. 

2.  Ocular  stigmata,  and 

3.  Aural  stigmata. 

Dental  Stigmata. — The  dental  stigmata  of  hereditary  syph- 
ilis are  due  to  arrested  development  of  the  teeth  in  the  process 
of  formation.  Permanent  incisors  and  the  sixth-year  molars 
are  the  teeth  most  often  affected  because  they  are  in  process  iD'f 
formation  during  the  first  three  months  of  extra-uterine  life, 
i.  e.,  at  the  very  time  when  hereditary  syphilis  shows  its  great- 
est virulence. 

Hereditary  syphilis  may,  however,  impart  to  the  teeth 
almost  any  malformation  in  size,  position,  and  shape.  Four- 
nier,  who  has  made  a  special  study  of  this  matter,  describes 
some  ten  varieties  of  syphilitic  dental  deformities.  But  we 
need  not  follow  thus  far,  for  these  deformities  are  not  in  them- 
selves in  the  least  pathognomonic.  They  suggest  syphilis  only 
when  they  are  associated  with  other  more  typical  lesions.  But 
there  are  two. striking  dental  deformities,  Hutchinson's  teeth 
the  more  typical,  Fournier's  the  more  common. 

Hutchinson's  Teeth. — This  deformity,  though  not  pecul- 
iar to  any  tooth,  is  usually  confined  to  the  permanent,  upper, 


HUTCHINSON'S    TRIAD 


535 


median  incisors.  It  is  not  absolutely  pathognomonic  of  syphilis 
(as  Hutchinson  thought),  for  several  authors  have  reported 
cases  of  syphilitic  teeth  in  non-syphilitic  persons,  and  the  ac- 


FiG.  68. — Hutchinson's  Teeth.     (From  a  cast.) 

companying  illustration   (Fig.  68)    is  drawn  from  a  cast  of 
such  a  case  taken  by  my  father. 

Typical  Hutchinson's  incisors  are  abnormally  small,  pegged 
(i.  e.,  tapering  inward  from  above  downward),  and  show  a 


Fig.   6-). — Irregular  and  Decayed  Teeth  Occurring   in   an  Hereditary 
Syphilitic,  but  in  no  Way  Characteristic  of  the  Disease. 

peculiar  erosion  of  the  free  border.  This  erosion  forms  an 
absolutely  regular  crescentic  bevel  of  the  anterior  surface  of 
the  free  border  of  the  tooth.     When  the  tooth  erupts  its  free 


536  HEREDITARY    SYPHILIS 

border  is  quite  rough,  but  this  roughness  rapidly  wears  away, 
leaving  a  typical  Hutchinson's  tooth,  which  retains  its  char- 
acteristics for  some  fifteen  or  twenty  years.  But  by  the  time 
the  patient  reaches  the  age  of  twenty  or  twenty-five  the  bevel 
edge  is  all  worn  off.  Hutchinson's  teeth  are  almost  always 
symmetrically  bilateral,  and  affect  the  permanent,  upper,  cen- 
tral incisors,  which  are  often  somewhat  displaced,  usually  con- 
verging toward  each  other. 

Fournier's  Teeth. — Fournier  has  described  a  less  char- 
acteristic deformity  of  the  sixth-year  molar,  which  he  says  is 
even  more  common  than  Hutchinson's  teeth. 

The  deformity  consists  in  an  erosion  of  the  summit  of  the 
tooth.  About  three  fourths  of  the  tooth  is  entirely  normal; 
the  terminal  fourth  "  is  diminished  in  all  its  diameters,  irregu- 
lar, eaten,  as  though  atrophied,  and  separated  from  the  healthy 
part  by  a  circular  ridge."  After  five  or  ten  years  of  use  this 
eroded  crown  wears  away,  leaving  a  short  tooth  with  a  smooth 
top,  to  which  Fournier  attaches  considerable  diagnostic  sig- 
nificance. 

Ocular  Stigmata. — Of  these,  the  most  striking,  though  by 
no  means  the  most  pathognomonic,  is  interstitial  keratitis  or 
the  scars  thereof.  Iritic  adhesions,  though  rarer,  are  almost 
equally  suggestive.  But  the  most  typical  stigmata  are  the  white 
scars  and  the  deposits  of  pigment  left  by  syphilitic  choroiditis 
(page  416).  Ocular  palsies  are  relatively  rare  in  young  syphi- 
litics,  but  they,  too,  may  leave  traces  suggestive  of  the  disease. 

Auditory  Stigmata. — Deafness  may  result  either  from 
lesions  of  the  middle  ear  or  from  those  of  the  inner  ear  or  of 
the  nerve.  Middle-ear  deafness  is  only  indirectly  due  to  syphi- 
lis, and  is  much  more  often  due  to  other  causes. 

But  internal  ear  or  "nerve  "  deafness  (page  395)  in  chil- 
dren or  young  persons  is  almost  exclusively  due  to  syphilis. 


DIAGNOSIS    OF    HEREDITARY    SYPHILIS  537 

DIAGNOSIS    OF    HEREDITARY    SYPHILIS 

In  order  to  disclose  a  case  of  hereditary  syphilis  one  may 
have  to  conduct  a  diagnosis  along  three  lines : 

1.  Examination  of  the  infant  and  study  of  its  history, 

2.  Study  of  the  history  of  previous  or  subsequent  births 
or  miscarriages,  and 

3.  History  of  the  father  and  mother  in  reference  to  ante- 
cedent syphilis. 

Needless  to  say,  this  investigation  must  often  be  carried  on 
with  the  greatest  discretion  and  with  the  most  delicate  regard 
for  the  feelings  of  the  parents  as  well  as  for  their  ignorance. 
Yet  when  one  is  satisfied  that  an  infant  is  syphilitic  and  infec- 
tious one  cannot  compromise  the  issue,  but  must,  for  the  safety 
of  the  community,  declare  to  the  parents  that  it  is  suffering 
from  an  infectious  disease,  though  it  may  be  discreet  to  with- 
hold from  the  mother  at  least  its  "  venereal  "  nature. 

Diagnosis  in  Infancy. — During  the  first  three  months  the 
symptoms  most  likely  to  be  discovered  are  snuffles,  erosions 
about  the  lips  and  anus,  skin  lesions,  bone  lesions — especially 
slight  irregularities  or  enlargements  at  the  ends  of  the  diaphy- 
ses  of  the  long  bones,  enlargement  of  the  liver  and  spleen,  and 
the  pinched,  clawlike  nails;  while  as  early  signs,  restlessness 
and  unaccountable  loss  of  weight  are  very  suggestive  of  syphi- 
lis. Later,  nodes  on  the  long  bones,  condylomata,  and  perhaps 
tertiary  lesions  of  the  throat,  with  gummata  or  some  one  of  the 
visceral  lesions  mentioned,  may  help  fill  out  the  picture.  Of 
these  lesions,  the  only  ones  likely  to  leave  an  imprint  in  later 
years  on  the  parents'  minds  or  the  child's  body  are  the  bone 
lesions,  the  lip  erosions,  and  perhaps  a  vague  history  of  snuf- 
fles, feebleness,  and  a  rash  in  infancy. 

Examination  of  the  Family  Record. — Every  syphilitic 
family  may  be  depended  upon  to  give  a  history  of  at  least  one 
miscarriage  or  one  death  in  infancy.     From  a  diagnostic  point 


238  HEREDITARY    SYPHILIS 

of  view,  however,  miscarriages,  unless  many  times  repeated, 
are  not  strong  presumptive  evidence,  since  they  occur  from  all 
manner  of  causes ;  and  it  might  equally  be  said  that  every  fam- 
ily, whether  syphilitic  or  not,  gives  a  history  of  at  least  one 
miscarriage;  with  this  difference,  however,  that  the  syphilitic 
family  has  the  miscarriage  at  the  head  of  the  list. 

Deaths  in  infancy  are  far  more  striking  presumptive  evi- 
dence, and  a  combination  of  several  miscarriages,  stillbirths, 
and  deaths  in  infancy  is  peculiarly  suggestive. 

History  of  the  Parents. — In  about  one  quarter  of  all  cases 
no  syphilitic  history  can  be  obtained  from  the  mother.  In 
many  cases  no  syphilitic  history  will  be  obtained  from  either 
parent.  Ignorance  or  fear  prompt  the  denial.  In  the  case  of 
the  mother  the  investigation  should  be  carried  out  solely  with 
regard  to  the  symptoms  of  the  disease,  though  the  father  may 
be  flatly  questioned  as  to  whether  he  ever  had  a  chancre. 

Diagnosis  in  Later  Years.  — In  later  years  we  have — besides 
the  actual  lesions  of  syphilis,  which  may  be  present  upon  the 
child's  body,  and  the  history  of  past  syphilis  in  the  child,  in 
his  brothers  and  sisters,  or  in  his  father  and  mother — a  set 
of  lesions  known  as  the  stigmata  of  hereditary  syphilis,  which 
may  help  materially  in  the  diagnosis  (page  532). 

The  presence  of  such  conditions  as  adenoids,  club-foot,  or 
idiocy  cannot  be  fairly  attributable  to  syphilis,  as  many  writers 
have  attempted  to  do. 

Rickets  and  tuberculosis,  though  common  complications  of 
hereditary  syphilis,  are  by  no  means  reliable  stigmata. 

Of  the  five  types  of  important  stigmata  previously  described, 
the  radiating  scars  over  the  lips  (resembling  the  radiating 
wrinkles  seen  in  the  aged)  are  alone  accepted  as  pathogno- 
monic by  Hochsinger.  Yet  a  typical  saber-blade  tibia,  a  pair 
of  Hutchinson's  teeth,  or  the  scars  of  an  interior  or  dis- 
seminated irido-choroiditis  are  almost  equally  convincing. 
But  one  rarely  has  to  depend  upon  one  lesion.     A  careful 


TREATMENT    IN    INFANCY  539 

examination,  if  it  reveals  anything  at  all,  usually  reveals 
enough  strongly  suggestive  stigmata  and  history  to  produce 
certainty  in  the  mind  of  the  examiner. 


PROGNOSIS 

The  general  prognosis  of  hereditary  syphilis  is  best  illus- 
trated by  the  figures  of  Dr.  James  Nevins  Hyde,  who  records 
1,700  pregnancies,  of  which  only  1,121  went  to  term,  while 
of  these,  916  died  within  the  first  year.  In  private  practice 
one  can  do  much  better  than  this,  though  how  much  better  is 
a  matter  of  doubt. 

As  already  stated,  pemphigus,  visceral  disease,  and  osteo- 
chondritis are  peculiarly  ominous. 

In  infancy  death  occurs  from  convulsions,  pneumonia,  and 
digestive  complications,  and  the  surviving  children  are  rela- 
tively hard  to  rear  and  subject  to  intercurrent  disease. 

The  three  important  elements  in  prognosis  are : 

1.  The  more  or  less  undeterminable  condition  of  the 
viscera. 

2.  The  food ;  for,  as  a  general  rule,  breast-fed  babies  have 
a  fair  chance  of  surviving,  while  bottle-fed  babies  have  a  very 
small  one. 

3.  Intelligent  administration  of  mercury. 

TREATMENT    IN    INFANCY 

The  treatment  of  hereditary  syphilis  is  based  upon  the  same 
rules  as  is  that  of  acquired  syphilis,  with  the  important  differ- 
ence that  our  hygienic  efforts  are  confined  almost  solely  to 
the  matter  of  diet,  mother's  milk  being  almost  as  important 
as  doctor's  mercury. 

There  is  this  further  distinction  to  be  made  in  the  matter 
of  mercurial  treatment  that,  if  the  mother  is  properly  treated 


540 


HEREDITARY    SYPHILIS 


with  mercury  during  her  pregnancy,  the  hereditary  syphilis 
should  be  prevented  and  the  child  be  born  at  term  uninfected. 

Fournier  would  have  us  treat  these  apparently  uninfected 
children  as  though  they  had  syphilis,  hoping  thus  to  forestall 
an  unsuspected  latent  disease.  But  other  authorities  do  not 
follow  this  rule. 

The  duration  of  routine  treatment  in  infancy  should  cover 
the  first  two  years,  just  as  in  adult  life.  Certain  practitioners 
are  in  the  habit  of  renewing  treatment  at  the  period  of  second 
dentition  and  again  at  puberty ;  yet  it  seems  wiser  not  to  employ 
this  routine  practice,  but  simply  to  warn  the  parents  that,  if 
the  child  shows  any  deterioration  in  its  health  or  local  signs  of 
syphilis,  at  these  times,  it  should  be  treated.  Indeed,  a  very 
brief  treatment  may  suffice  to  quell  the  disease.  Thus  Hutch- 
inson advises  that  treatment  be  stopped  with  the  cessation  of 
symptoms;  and  Hochsinger,  who  continues  treatment  only  a 
fortnight  thereafter,  states  that  eighty-five  per  cent  of  the  re- 
lapses seen  by  him  from  the  fourth  to  the  sixth  month  were  in 
untreated  cases.  But  it  is  the  part  of  wisdom  to  clinch  the 
advantage  gained  by  a  course  similar  to  those  employed  in  the 
adult  and  covering  the  first  two  years.  In  infancy,  however, 
two  rules  apply : 

1.  lodid  of  potassium  is  useless  in  the  first  year. 

2.  Mercury  may  be  given  by  mouth  or  by  inunction.  Intra- 
muscular injections  have  found  little  favor,  though  the  employ- 
ment of  both  the  soluble  and  the  insoluble  salts  has  been  urged. 

The  usual  treatment  consists  in  the  application  of  the  offi- 
cinal ung.  hydrargyri,  diluted  with  two  or  three  parts  of  vase- 
lin  (reducing  it  to  one  third  or  one  quarter  strength).  This 
is  laid  on  the  belly  band  and  renewed  with  it.  No  special  pre- 
cautions need  be  taken  to  prevent  irritation  of  the  skin,  and 
the  application  may  be  continued  daily  throughout  the  treat- 
ment with  only  such  intermissions  as  may  be  required  by  the 
appearance  of  diarrhea,  dermatitis,  or  intercurrent  disease. 


TREATMENT  OF  RELAPSES  AFTER  THE  SECOND  YEAR     541 

Infants  bear  mercury  very  kindly,  and  do  not  become  sali- 
vated. 

For  internal  administration  (if  inunction  proves  inefficient 
or  irritating)  gray  powder  is  usually  employed,  mixed  with 
two  or  three  parts  of  sugar.  Beginning  with  a  quarter  or  half 
a  grain  t.i.d.,  the  dose  is  rapidly  increased  to  a  grain  t.i.d.  .  For 
a  more  rapid  effect,  Holt  employs  calomel,  gr.  yq,  q.i.d.,  until 
the  bowels  are  touched. 

Injections  may  be  employed  in  about  one  tenth  the  adult 
dose,  and  this  may  be  doubled  at  the  time  of  second  dentition, 
and  trebled  thereafter. 

Local  Treatment. — The  baby's  skin  must  be  kept  abso- 
lutely clean  and  dry,  diapers  frequently  changed,  and  powder 
freely  used.  Erosions  and  condylomata  are  to  be  treated,  as 
in  the  adult,  by  drying  and  calomel  powder;  but  it  is  safer  to 
dilute  the  calomel  with  two  parts  of  starch  or  talcum  powder. 

The  nasal  congestion  in  snuffles  may  be  somewhat  reduced 
by  anointing  the  inside  of  the  nose  with  ammoniated  mercury 
ointment.  Since  stomatitis  does  not  occur  in  infancy,  no  espe- 
cial care  of  the  mouth  is  required;  but  erosions  and  fissures 
upon  the  lips  may  be  touched  once  a  week  with  the  nitrate-of- 
silver  stick. 

It  is  safer,  as  a  general  rule,  not  to  incise  the  furunculoid 
lesions,  inasmuch  as  they  are  discrete  and  are  often  cheesy 
rather  than  suppurative;  but  when  at  the  surface  or  already 
burst,  they  should  be  cleansed  daily,  or  twice  a  day,  with  hy- 
drogen peroxid  diluted  to  one  half  strength. 

TREATMENT   OF   RELAPSES  AFTER   THE   SECOND    YEAR 

In  childhood,  and  especially  at  the  time  of  the  second  denti- 
tion, the  outbreak  of  tertiary  symptoms  may  require  mixed 
treatment. 

The  iodid  is  then  to  be  administered  quite  as  for  adults. 


542 


HEREDITARY    SYPHILIS 


It  is  well  borne,  and  the  initial  dose  may  be  from  three  to  five 
grains  t.i.d. 

Mercury  may  be  given  in  from  one  third  to  one  half  the 
adult  dose,  but  injections  should  be  given  at  about  one  fifth 
strength. 

It  must  not  be  forgotten  that  no  amount  of  treatment  will 
reduce  an  organized  deposit  of  bone  caused  by  diffuse  perios- 
titis, and  that  parenchymatous  keratitis  seems  to  run  its  course 
quite  independently  of  antisyphilitic  treatment,  though  this  is 
habitually  employed. 


INDEX 


Aachen,  treatment  of  syphilis  at,  141. 
Abadie,  190. 

Abducens,  paralysis  of,  388. 
Abscess  distingmshed  from  subcutane- 
ous gumma,  332. 
from  mercurial  injection,  184. 
Absence  of  inflammation  in  syphilis,  272. 
of  pain  and  itching  in  syphihs,  272. 
of  primary  lesion  in  men,  45,  82. 
in  women,  45,  79,  237. 
Absorption  of  mercury,  161. 
Acne,   differentiation  of,   from  papular 
syphiKd,  292. 
from  syphilis,  295. 
iodic,  194. 

differentiated  from  syphilis,  295. 
Acneiform  syphilid,  293. 
diagnosis  of,  295. 
hereditary,  512. 
of  the  scalp,  295. 
Acquired  syphiHs,  13. 
Adenitis,      diagnostic     importance     of 
syphilitic,  118. 
of  chancre,  238. 
of  chancroid,  214. 

treatment  of,  221. 
of  early  syphilis,  261. 
of  .hereditary  syphilis,  521. 
peribronchial,  461. 
secondary,  261. 
tertiary,  490. 
Adenomatous  syphilitic  pneumonia,  463. 
Administration  of  mercury,  154,  169. 

of  iodides,  196. 
Age,   effect  of,   on  syphilis  of  nervous 
system,  369. 
in   diagnosis   of   syphiUs   of   nervous 
system,  409. 


Age,  in  prognosis  of  syphilis,  128. 
of  onset  of  syphilis,  58. 
of  tabes,  108. 
Air  passages,  syphilis  of,  452. 
Albuminuria,  iodic,  195. 
mercurial,  165,  497. 
syphihtic,  165,  497. 
Alcohol,  effect  of,  on  syphilis  of  nervous 
system,  370. 
on  tertiary  relapses,  103. 
Alcohol  and  syphilis,  19,  129. 
Alexander,  531. 
Alopecia    areata,     diagnosis    of,     from 

syphihtic  alopecia,  267. 
Alopecia  of  syphiHs,  265. 
American  method  of  treating  syphilis, 

154. 
Ammonium  iodid,  199. 
Amyloid  degeneration,  syphihtic,  270. 
Amyloid  kidneys,  496. 
Amyloid  hver  complicating  syphilis,  472. 
Anal  chancre,  238. 
Anal  mucous  papules,  302. 

diagnosis  of,  345. 
Andre, .27. 
Andry,  190. 

Anemia  of  early  syphihs,  254. 
Anemia    pseudo-leukemia   infantum   in 

hereditary  syphilis,  527. 
Anesthesia  in  spinal  syphilis,  404. 
Aneurysm,  aortic.  See  Aortic  Aneurysm, 
of  arteries  of  extremities.    See  Arteries. 
Angina  of  Vincent,  249. 
Angina  pectoris,  syphilitic,  4S6. 
Animal  inoculations,  30. 
Ankle  clonus  in  spinal  syphihs,  403. 
Ano-gcnital  lesions  of  hereditarv  syphilis, 
S16. 

543 


544 


INDEX 


Ano-rectal  syphiloma,  494. 
Anterior  chorio-retinitis,  418. 
Antip3'rin  erj'thema,   differentiation  of, 

from  macula  syphilid,  283. 
Aorta,  syphilis  of,  4S7. 
Aortic  aneurysm,  487. 
diagnosis  of,  488. 
frequency  of,  488. 
incidence  of,  488. 
treatment  of,  488. 
Aphasia,  395 .    S  ee  also  Nervous  System , 
Syphilis  of. 
a  prodrome    of   syphiHs    of   ner\'ous 

system,  380. 
date  of  onset  of,  372. 
Aphonia,  454,  457. 

in  hereditary  s)'philis,  518. 
Aphthous  erosions,   distinguished  from 

s}'philis,  344. 
Aponeuroses,  syphilis  of,  449. 
Apoplexy,     sj'philitic,     389.     See     also 
Nervous  System,  SyphiHs  of. 
date  of  onset  of,  372. 
Appendicitis  and  syphilis,  494. 
Arg}'ll-Robertson  pupil,  405. 

in  tabes,  no. 
Arkansas,  Hot  Springs  of,  141. 
Army,  prevalence  of  syphilis  in,  3. 
Arrest    of    development    in    hereditary 

sj'philis,  525,  533. 
Arrh}i;hmia,  cardiac,  485. 
Arteries,  coronar}',  syphilis  of,  486. 
Arteries  of  the  brain,  gumma  of,  374. 
lesions  of,  373. 
s}TDhilis  of,  symptoms  of,  3S2. 
of  extremities,  syphilis  of,  488. 
diagnosis  of,  489. 
obstructive,  489. 
s}'phiHtic  aneur}'sm  of,  489. 
Arterio-sclerosis  and  syphihs,  106,  270. 
Arthralgia,  264. 

secondary  sj'philitic,  444. 
Arthritis,  diagnosis  of,  447. 
hereditary  syphilitic,  521. 
patholog}^  of,  446. 
statistics  of,  446. 
tertiary  syphilitic,  445. 
treatment  of,  447. 


Arthritis  deformans,  447. 
.Articulations,  syphilis  of,  444. 
Ascites  in  hereditary  syphihs,  522. 

in  liver  syphilis,  473. 
AsKPiAxz,  207. 
Asphyxiation  from  edema  of  glottis,  458. 

from  inspiration  pneumonia,  466. 
Ataxia,  locomotor.     See  Tabes. 

in  spinal  syphihs,  405. 

syphihtic,  with  exaggerated  reflexes, 
407. 
Atoxj'l,  145. 
Atrophic  onychia,  309. 
Atrophic  rhinitis,  366. 
Atrophy  of  optic  ner\^e,  420. 
Atropin  in  treatment  of  iritis,  415. 
Auditory  canal,  syphihs  of  external,  347. 
Auto-inoculation  of  chancre,  225. 

of  chancroid,  216. 

Bab,  53. 
Balzer,  462.  • 
Ba^jdi,  25. 

BARTHELEilY,   75. 

Beer,  30. 

Beneficial  effects  of  mercur}-,  161. 

Bensatjde,  492. 

Benzoate  of  mercurj',  injections  of,  175. 

Berd.ax,  178.  . 

Bergeron,  22. 

Beriel,  462. 

Berkley,  107,  374,  399. 

BeRTARELLI,   22,   31. 

Bichlorid  of  mercur}',  171. 
injection  of,  174. 
intravenous,  189. 
Bicipital  contracture,  447. 
Bilateral  hemiplegia,  391. 
Bilateral  iritis,  411. 
Bilateral  keratitis  in  hereditan,-  syphihs, 

531- 
Bilateral  lesions  in  bone  syphihs,  424. 
Bilateral  optic  neuritis,  386,  420. 
Bilateral  orchitis,  478. 
Biniodid  of  mercury',  170. 
injection  of,  175. 
intravenous,  189. 
Biopsy  in  chagnosis  of  sypliihs,  116,  328. 


INDEX 


545 


BiRT,  269. 

Black  oxid  of  mercun'  for  fumigation, 

1S8. 
Bladder,  syphilis  of,  501. 
Blaschko,  133. 

Blindness,  due  to  optic  neuritis,  421. 
Blood,  in  earh'  syphilis,  254. 
infection  from,  54. 
infectiousness  of,  32. 
spirochetae  in,  28. 
Bloody  scabs,  a  sign  of  nasal  gumma, 

366. 
Blue  ointment,  1S5. 

in  hereditary  syphilis,  540. 
Blue  pill,  171. 
BOERIIANX,  32. 

Bone,    callus    of,    differentiated    from 
syphilis  of,  437. 
gumma  of,  431. 

s}Tnptoms  of,  432-434. 
hereditary  syphilis  of,  518. 
lesions  of,  in  rachitis  similar  to  those 

of  hereditary'  syphilis,  528. 
neoplasm  of,  differentiated  from  syph- 
ilis, 436. 
Bone  syphiUs,  424.    See  also  Osteo-peri- 
ostitis  and  Special  Bones. 
compHcations  of,  436. 
diagnosis  of,  436. 
etiology  of,  426. 
multiple  lesions  of,  426. 
occurrence  of,  425. 

table  of,  425. 
pathology  of,  427. 
prognosis  of,  438. 
sjTTiptoms  of,  433. 
treatment  of,  437. 
Bone    tuberculosis    differentiated    from 

syphiUs,  436. 
Bones  of  orbit,  syphilis  of,  423. 

nervous  symptoms  due  to,  388. 
BORDET,  22. 
BOVERO,   22. 

Bradycardia,  486. 
Brain,  gumma  of,  375. 
Brain   syphilis.       See  also    Sypliihs   of 
Nervous  System, 
arterial  lesions  of,  373. 


Brain  syphilis,  diagnosis  of,  409. 
meningeal  lesions  of,  374. 
pathology  of,  373. 
Breast,  chancre  of,  238. 
Bright's    disease,    sypliilitic.     See    Ne- 
phritis. 
Broich,  55. 

Bronchi,  gtunma  of,  461. 
rupture  of  gumma  into,  465. 
syphilis  of,  460,  466. 
diagnosis  of,  468. 
patholog)'  of,  460. 
treatment  of,  468. 
ulceration  from,  461. 
Bronchiectasis,  syphihtic,  465. 
Bronchitis,  acute  secondar}-,  466. 

compHcating  syphihs  of  lung,  465. 
Broncho-pneumonia,  complicating  s}'ph- 
ihs  of  lung,  465. 
in  hereditary  syphilis,  466,  523. 
Broncho-pneumonic  type  of  pulmonar}' 

syphilis,  467. 
Brooks,  Hexry,  231. 
Bross,  133. 

Brown-Sequard  paralysis,  407. 
Bruhns,  486. 
Bruises,  syphihs  of,  39. 
Bubo.     See  Adenitis. 
BtJCHLER,  55. 

BULKLEY,   55,  56. 

Bulimia  mth  syphihtic  fever,  258. 
BxJLL,  418,  419. 
Bullae,  iodic,  194. 
Bullous  sA'phiUd,  292. 

hereditar}',  513. 
Bursse,  syphihs  of,  449. 

Cachectic  tj-pe  of  S3'philis  of  liver,  476. 
Cachexia,  chronic  syphihtic,  267. 
treatment  of,  141. 
from  syphilis  of  Uver,  474. 
Calcaneum,    occurrence  of  syphilis  in, 

425- 
Calcium  iodid,  199. 
Callus,  differentiation  of,  from  syphilis 

of  bone,  437. 
Calomel,  171. 

for  chancroids,  219. 


546 


INDEX 


Calomel,  for  condylomata,  346. 

for  hereditary  syphilis,  541. 

for  fumigation,  188. 

injections  of,  176. 
Calomelol  ointment,  185. 
Cancer.     See  Neoplasm. 
Capillary  lesions  of  syphilis,  48. 
Carcinoma.     See  Neoplasm. 
Cardiac  syphilis.       See  Heart. 
Care  of  the  teeth,  163. 
Carpenter,  517,  522. 
Cases.     See  Cases  Cited  xxv. 
Castellani,  122. 
Cause.     See  Etiology. 
Causes  of  death  in  syphihs,  136. 
Cauterization  of  chancre,  6,  32. 

of  chancroid,  218. 

of  leukoplakia,  355. 

of  mouth  ulcers  and  mucous  papules, 
346. 
CcUuHtis,  pelvic,  502. 
Central  chorio-retinitis,  418. 
Cerebral  lesions.     See  Brain. 
Cerebral  arteritis,  373. 

symptotas  due  to,  382. 
Cerebro-spinal  fluid,  lymphocytosis  of, 

376- 
Cervix,  chancre  of,  236. 
Cervical  nodes  in  early  syphilis,  263. 
Chancre,  222.    See  also  Primary  Lesion. 

adenitis  of,  238.     See  also  Adenitis. 

auto-inoculation  of,  225. 

bubo  of,  238. 

buccal,  237. 

differential  diagnosis  of,  249. 

causes  of,  32. 

characteristics  of,  234. 

complications  of,  228, 

diagnosis  of,  242. 

duration  of,  233. 

eroded,  226. 

exceptional  varieties  of,  2 28. 

extra-genital,  56,  237. 

differential  diagnosis  of,  249. 

gangrenous,  230. 

herpetiform,  228. 

indurated  papule,  228. 

inflamed,  230. 


Chancre,  inflamed,  local  treatment  of, 

233- 
l3Tnphangitis  of,  228. 
multiple,  224. 

location  of,  225. 
number  of,  225. 
of  anus,  238. 
of  breast,  238. 
of  cervix,  236. 
of  conjunctiva,  238. 
of  corona,  234. 
of  eyelid,  238. 
of  finger,  238. 
of  glans  penis,  234. 
of  gum,  237. 
of  lip,  237. 

differential  diagnosis  of,  249. 
of  meatus,  234. 
of  mouth,  237. 

differential  diagnosis  of,  249. 
of  prepuce,  234. 
of  pubes,  234. 
of  rectum,  238. 
of  tongue,  237. 

differential  diagnosis  of,  251. 
of  tonsil,  237. 

may  be  due  to  a  kiss,  56, 
of  urethra,  235. 

frequency  of,  82. 
of  vulva,  235. 
pathology  of,  223. 
phagedenic,  230. 
prognosis  of,  233. 
redux,  481. 

diagnosis  of,  483. 

differential  diagnosis  of,  245. 

mistaken  for  chancre,  44. 

occurrence  of,  482. 

symptoms  of,  482. 

treatment  of,  483. 
reinduration  of,  233. 
synonyms  of,  222. 
transformation    of,    into    a    mucous 

papule,  233. 
treatment  of,  233. 
types  of,  225. 
ulcerated,  226. 
unusual  varieties  of,  228. 


INDEX 


547 


Chancre,  urethral,  235. 
vaccinal,  238. 
vegetation  of,  233. 
Chancroid,  206. 
abortion  of,  217. 
bubo  of,  214. 
calomel  for,  219. 
cause  of,  206. 
cauterization  of,  217. 
complications  of,  212. 

treatment  of,  219. 
contagiousness  of,  208,  209. 
course  of,  210. 
definition  of,  206. 
diagnosis  of,  216. 
differential  diagnosis  of,  from  chancre, 

245-246. 
frequency  of,  208. 
gangrene  of,  214. 
incubation  of,  210. 
inflamed,  213. 
iodoform  for,  219. 
local  treatment  of,  217. 
lymphangitis  of,  214. 
nosophen  for,  219. 
number  of,  210. 

of  female  genitals,  differential  diagno- 
sis of,  345. 
onset  of,  211. 
palliation  of,  219. 
phagedena  in,  214. 
situation  of,  209. 
symptoms  of,  210. 
treatment  of,  217. 
abortive,  217. 
adenitis  of,  221. 
complications  of,  220. 
palliative,  219. 
Characteristics  of  syphilids,  clinical,  271. 
pathological,  278. 
of  syphilis,  11. 
Charcot  joint,  405. 
Charpentier,  405. 
Chatin,  492. 
Chetwood,  201. 
Chichkoff,  352. 
Chlorate  of  potash,  163,  165. 
Chloroanemia  of  early  syphilis,  254. 
37 


Choc  en  retoitr,  46. 
Choked  disc,  420. 
Chorio-retinitiSj  416. 
anterior,  418. 
disseminate,  418. 

in  hereditary  syphiHs,  416,  418,  536. 
pathology  of,  416. 
prognosis  of,  419. 
symptoms  of,  417. 
treatment  of,  419. 
varieties  of,  418. 
Choroid,  gumma  of,  421. 
Ciliary  body,  syphilis  of,  421. 
Circle  of  Venus,  292,  314. 
Circinate  macular  syphiUd,  284. 
Circinate     papulo-squamous     syphilid, 

299. 
Circinate  shape  of  syphilids,  273. 
Circinate  tubercular  syphilid,  314. 
Circinate  ulcerative  syphilid,  319. 
Circulatory  system,  syphilis  of,  484. 
Circumcorneal  injection  in  iritis,  413. 
Cirrhotic  type  of  liver  syphilis,  475. 
Civilization,  effect  of,  on  parasyphilids, 
107. 
on  syphilis  of  nervous  system,  370. 
Clavicle,  occurrence  of  syphilis  in,  425. 
Climate  and  syphihs,  127. 
Chnical  characteristics  of  syphilids,  271. 
Clinical  types  of  syphilis,  18. 

of  syphilis  of  nervous  system,  386. 
Coatsleeve  exudation,  48. 
Colitis,  syphilitic,  493. 
Colles's  law,  16,  70. 

exceptions  to,  71. 
Color  of  syphilids,  273. 
Comparison  of  methods  of  administering 

mercury,  191. 
Concurrence    of   lesions   in   syphilis   of 
nervous  system,  372,  381,  409. 
of  tertiary  lesions  in  the  mouth,  351. 
Condyloma,  340. 
diagnosis  of,  345. 
in  hereditary  syphilis,  527. 

treatment  of,  541. 
of  anus,  340. 
of  face,  312. 
of  genitals,  340. 


548 


INDEX 


Condyloma,  of  iris,  412. 

of  larynx,  453. 

of  mucous  membranes,  340. 

treatment  of,  346. 

ulcerated,  342. 
Confluence  of  hereditary  s3qDhilids,  513. 
Confluent  gumma,  331. 
Confluent  papular  sypliilid,  287. 
Confluent  tubercular  syphilid,  314. 
Confrontation  in  diagnosis  of  chancre, 

242. 
Congenital  immunity  to  syphilis,  125. 
Congenital   syphilis.        See  Hereditary 

Syphilis. 
Conjunctival  chancre,  238. 
Conjunctival  gumma,  422. 
Conjunctival  syphilis,  422. 
Conjunctivitis,  papular,  422. 
Connors,  60. 
Constitution,     effect    of    patient's,     on 

prognosis  of  syphilis,  125. 
Contagiousness.     See  Infectiousness. 

CONTAMINE,    45. 

Continuous  tonic  treatment,  154. 
Contraction,  muscular,  448. 
Convulsive    prodromes    of    sypliilis    of 

nervous     system     uncommon, 

380. 
Copaibal  erythema  differentiated  from 

macular  syphilid,  286. 
Cord,  syphilis  of  spinal.        See  Spinal 

Syphilis. 
Corneal  gumma,  422. 
Corneal  syphilis.      See  Keratitis. 
Corona  veneris,  292,  314. 

differentiated  from  acne,  292. 
Coronary  arteries,  syphilis  of,  486. 
Corrosive  subhmate.      See  Bichlorid  of 

Mercury. 
Coryza,  in  hereditary  syphihs,  510. 

iodic,  193. 
Course  of  syphilis,  78. 
Cranial  bones,  syphilis  of,  339. 
Craniotabes,  520. 
Crossed  bubo,  239. 
Crust  of  syphilids,  274. 
Crusted  syphilid.    See  Pustular  Syphilid. 
Crusted  tubercular  syphilid,  322. 


CULLERIER,   209. 
CUMSTON,  474. 

Cytorryctes  Luis,  22. 

Dacryoadenitis,  423. 
Dactylitis,  441. 

in  hereditary  syphilis,  520. 

occurrence  of,  425. 
D'Amato,  269. 
Dana,  376. 
Danger  of  extragenital  infection,  51. 

of  hereditary  syphilis,  65. 

of  infection  from  blood,  54. 
from  exposure,  59. 
from  tertiary  lesions,  36. 

of  marital  infection  instant,  62. 
Darier,  488. 
Davis,  Lincoln,  207. 
Deafness,  395. 

association  of,  \\dth  other  lesions  of 
nervous  system,  395. 

occurrence  of,  372. 

pathology  of,  395, 

prognosis  of,  396. 

symptoms  of,  396. 

treatment  of,  396. 
Death,  causes  of,  in  acquired  syphilis, 
136. 
in  fetal  syphilis,  507. 
in  hereditary  syphilis,  509,  525. 
DebiHty  and  syphilis,  128. 
Debility  in  early  syphilis,  259. 
Deferred  hereditary  syphilis,  17,  528. 

of  chancroid,  206. 
Definition  of  parasyphilids,  105. 

of  syphilis,  11. 
Deforming  arthritis,  447. 
Deformities  due  to  hereditary  syphilis, 

511,  525,  532. 
Degeneration  of  gumma,  328. 

of  larynx,  fibroid,  455. 

of  race  by  inherited  syphilis,  75. 
DeGraefe's   relapsing    central   retinitis, 

418. 
Deguy,  486. 

Delayed  hereditary  syphilis,  17,  528. 
Delusional  insanity,  399. 
Dementia,  date  of  onset  of,  372. 


INDEX 


549 


Dementia,  prognosis  of,  402. 

with  paralysis,  400. 

without  paralysis,  402. 
Dental  stigmata  of  hereditary  syphilis, 

534- 
Dermatitis,  iodic,  194. 

mercurial,  166. 
Desquamation  of  syphilids,  274,  288. 
Desquamative  pneumonia,  464. 
Destruction  of  nasal  septum,  364. 
Detachment  of  nail,  syphilitic,  310. 
Development,    arrested,    in    hereditary 
syphilis,  525. 

of  syphilids,  slow  and  progressive,  272. 
Diagnosis.     See  also  Differential  Diag- 
nosis. 

of  chancroid,  216,  246. 
Diagnosis  of  syphilis,  113. 

by  biopsy,  116,  328. 

by  history,  117. 

by  inoculation,  32,  116. 

by  Justus  test,  116. 

by  lymphadenitis,  118,  261. 

by  mouth  lesions,  118,  343. 

by  scars,  118,  274. 

by  serum,  34,  119. 

by  spirocheta,  26,  115,  243. 

by  tongue  lesions,  119. 

by  treatment,  119,  205. 

clinical,  117. 

during  initial  stage,  120,  242. 

during  intermission,  120. 

during  later  relapse,  121. 

during  secondary  outbreak,  120. 

hereditary,  537. 

laboratory,  115. 

of  nervous  system,  408. 
pathologic,  382. 

pathologic,  115,  32S. 
Diagnosis  of  syphilitic  aneurysm,  aortic, 
488. 
of  arteries  of  extremities,  489. 

arthritis,  447. 

bronchitis,  466. 

chancre,  242,  246. 
extragenital,  249. 
redux,  246,  483. 

deafness,  396. 


Diagnosis  of  syphilitic  aneurysm,  ero- 
sions, 343. 
facial  paralysis,  397. 
gumma,  328. 
iritis,  414. 
laryngitis,  454,  458, 
leukoplakia,  354. 
liver,  474. 
macule,  286. 
mouth  ulcers,  343. 
nephritis,  498. 
neuritis,  408. 
nose  lesions,  366. 
optic  neuritis,  421. 
papule,  291. 
paresis,  no. 

by  cerebrospinal  lymphocytosis,  376. 
pemphigus,  514. 
squamous  papule,  299. 

of  palms  and  soles,  308. 
spirocheta,  26. 
subcutaneous  gumma,  332. 
testicle,  481. 
tongue  gumma,  357. 
ulcers  of  mouth,  343. 

of  skin,  326. 
visceral  gumma,  332. 
Diarrhea,  mercurial,  165. 
Dieulafoy,  486. 

Differential    diagnosis    of    extragenital 
chancres,  249. 
of  genital  sores,  244. 
of  gumma.     See  Gumma, 
of  secondary  and  tertiary  syphilids,  83. 
of  syphilis,  121. 

and  acne,  292,  295. 

and  acne,  iodic,  295, 

and  alopecia  areata,  267. 

and  aphthous  erosions,  344. 

and  bone  callus,  437. 

and  chancroid,  245,  246. 
of  vulva,  345. 

and  cirrhosis  of  liver,  475. 

and  condylomata  acuminata,  345. 

and  ecthyma,  296. 

and  eczema,  273. 
of  palms,  308. 
of  scalp,  517. 


55° 


INDEX 


Differential   diagnosis   of    syphilis    and 
erosions  of  mouth,  251,  344. 
and  herpes  of  mouth,  344. 

progenitaHs,  244. 
and  impetigo,  295. 
and  leprosy,  300. 
and  lupus,  317,  327. 
and  lichen  planus,  221. 
and  mouth  ulcers,  251,  344. 
and  neoplasm,  328. 

of  bone,  437. 

of  intestine,  493. 

of  kidney,  500. 

of  larynx,  458. 

of  Hp,  249. 

of  liver,  473. 

of  rectum,  494. 

of  skin,  333. 

of  stomach,  493. 

of  testicle,  481. 

of  tongue,  357. 
and  osteomyelitis,  436. 
and  pemphigus  neonatorum,  514. 
and  psoriasis,  299. 

of  palms,  308. 
and  rachitis,  528. 
and  rheumatism,  445. 
and  ringworm,  300. 
and  scabies  of  penis,  245. 
and  seborrhea,  273. 
and  syphilophobia,  114. 
and  traumatic  mouth  ulcers,  251. 
and  tuberculosis,  328. 

of  bone,  436. 

of  kidney,  500. 
of  knee,  529. 
of  larynx,  458. 
of  lung,  468. 
of  spine,  443. 
of  testicle,  481,  521. 
and  ulcers,  buccal,  251,  344. 
genital,  246. 

leg,  334- 
and  Vincent's  angina,  249. 
and  vitiligo,  301. 
and  yaws,  122. 
Diffuse  infiltration  of  face,  312. 
of  larynx,  453. 


Diffuse  papular  syphilid,  291. 
hereditary,  514. 

Diffuse  sclerotic  glossitis,  356. 

Digestive  organs,  syphilis  of,  492. 

Dimness  of    vision    in    chorio-retinitis, 
417. 

Diplopia,    due    to    paralysis    of    motor 
oculi,  387. 

Discrete  gumma,  330. 

Discrete  tubercles,  314. 

Disseminate  chorio-retinitis,  418. 

DiSTEFANO,  199. 

Distribution  of  spirochetas,  27. 

Disturbance  of  reflexes  in  spinal  syph- 
ilis, 403. 

DOEVENSPECK,   199. 

Does  exposure  to  syphilis  imply  infec- 
tion? 59. 
Dorsal  incision  of  foreskin,  220. 
Drescheield,  521. 
Dreyer,  28. 
Dron,  479. 

Drug  eruptions  differentiated  from  mac- 
ular syphilid,  286. 
DuaHsts,  theory  of,  13. 
Dubreuilh,  207,  215. 
Ducrey,  streptobacillus  of,  206. 
Duration  of  chancre,  233. 

of  hereditary  infectiousness,  16. 

of  hereditary  syphilis,  528. 

of  incubation,  80. 

of  infectiousness,  61. 

of  secondary  lesions,  87. 

of  symptomatic  treatment,  149. 

of  syphilis,  132. 

of  tertiary  lesions,  104. 

of  tonic  treatment  of  syphilis,  157. 
Dyspnea  of  tracheal  syphihs,  460. 
Dystrophies  of  hereditary  syphilis,  525. 

Ear,  hereditary  syphilis  of,  523. 

hereditary  stigmata  of,  536. 

syphilis  of,  secondary,  347. 

syphiUs  of,  tertiary,  367. 
Early  painful  symptoms,  treatment  of, 

by  iodids,  147. 
Early  secondary  lesions,  85. 
Early  tertiary  lesions,  96. 


INDEX 


551 


Eczema,  differentiation  of,  from  heredi- 
tary syphilis  of  scalp,  517. 
of  the  palms,  differentiated  from  syph- 
ilis, 308. 
Eczema  and  syphilis,  273. 
Ecthyma,  differentiation  of,  from  syph- 
ilis, 296. 
syphilitic,  secondary,  296. 
syphilitic,  tertiary,  323. 
Edema  iodic,  195. 

Effect  of  alcohol  on  syphilis.       See  Al- 
cohol, 
of  hygiene  on  syphilis.     See  Hygiene, 
of  iodid  on  syphilis.     See  lodid. 
of  mercury  on  syphilis.     See  Mercury, 
of  treatment  on  syphilis.     See  Treat- 
ment. 
Efficiency  of  treatment,  signs  of,  157. 
Ehrmann,  47. 
Elevated  macules,  284. 
Elimination  of  mercury,  i6j. 
Embolism    from    mercurial    injections, 

182. 
Endocarditis,  syphilitic,  486. 
Endometritis,     erosions     from,     distin- 
guished from  syphilis,  345. 
syphihtic,  503. 
Enesol,  175. 

English  method  of  treatment,  154. 
Enlargement  of  spleen  in  early  acquired 
syphihs,  265. 
in  hereditary  syphiUs,  522. 
Enteritis,  syphilitic,  493. 
Entero-colitis,  mercurial,  165. 
Environment,  effect  of,  on  prognosis  of 

syphilis,  127. 
Eosinophilia  of  early  syphilis,  256. 
Epididymis,  syphilitic,  479. 
Epilepsy,  syphilitic,  398. 

a  prodrome  of  syphilis  of  nervous 

system,  380. 
date  of  onset  of,  372. 
hereditary,  525. 
Jacksonian,  398. 
Epilepsy  and  syphilis,  106. 
Epiphyscolysis    in    hereditary    syphilis, 

520. 
Episcleritis,  422. 


Epistaxis,  iodic,  195. 
Epithelioma,    differentiation    of,    from 
chancre  of  Kp,  249. 
from  gumma  of  the  tongue,  357. 
from  subcutaneous  gumma,  332. 

occurrence  of,  in  leukoplakia,  355. 
Epitrochlear  nodes  in  early  syphilis,  262. 
Erb's  syphilitic  spinal  paralysis,  112. 
Eroded  chancre,  226. 
Erosive  syphilid.     See  Mucous  Papules. 
Erythema  of  fauces,  337. 

of  larynx,  453. 

of  trachea,  460. 
Esophagus,  syphilis  of,  492. 
Esquimaux,  immunity  of,  against  syph- 
ilis, 41. 
Etienne,  487. 
Etiology  of  aneurysm,  487. 

of  bone  syphilis,  426. 

of  chancroid,  206. 

of  hereditary  syphilis,  16,  65. 

of  leukoplakia,  352. 

of  liver  syphilis,  469. 

of  malignant  syphilis,  ig. 

of  middle  ear  syphilis,  347. 

of  parasyphilids,  14,  40. 

of  paresis,  107. 

of  relapses  of  syphilis,  38,  94,  loi. 

of  secondary  relapses,  94. 

of  secondary  syphilis  of  mucous  mem- 
branes, 336. 

of  syphilis,  22. 

of  syphilis  of  nervous  system,  368. 

of  tabes  dorsalis,  107. 

of  tertiary  relapses,  loi. 

of  tertiary  syphilis  of  mucous  mem- 
branes, 350. 
Eustachian  tube,  secondary  syphilis  of, 

347- 
EWING,  23. 

Excision  of  bubo,  221. 
Expectation  of  life  of  syphiiitics,  136. 
Experimental  syphilis,  30. 
External  auditory  canal,  syphilis  of,  347. 
Extragenital  chancre,  56. 
Extragenital  infection,  54. 

cause  of,  40. 

frequency  of,  in  different  countries,  55. 


552 


INDEX 


Eye,  hereditary  syphilis  of,  523. 
stigmata  of,  536. 
in  paresis,  no. 
lesions  of,  in  spinal  syphilis,  405. 

in  tabes,  no,  387,  405. 
paralysis  of,  386. 
syphilis  of,  411. 
Eyelid,  chancre  of,  238. 

Face,  condyloma  of,  312. 

diffuse  infiltration  of,  312. 

syphilids  of,  312. 

hereditary,  513,  516. 

vegetations  of,  312. 
Facial  paralysis,  397. 

date  of  onset  of,  372. 
Fate  of  spirochetae,  29. 
Fauces.     See  Tonsils,  Pharynx. 
Febrile  type  of  hver  syphiUs,  476. 
Female.     See  Woman. 

chancre  of,  235. 

chancroid  of,  210. 
Female  genitals,  erosion  of,  differential 

diagnosis  of,  345. 
Femur,  occurrence  of  syphilis  in,  425. 
Fetal  syphilis,  17,  506. 

pathology  of,  506. 

symptoms  of,  507. 
Feuerstein,  116. 
Fever  of  early  syphiHs,  257. 

of  late  syphiKs,  268. 
Fibroid  degeneration  of  larynx,  455. 
Fibula,  occurrence  of  syphilis  in,  425. 
Finger,  32,  45,  71,  75. 
Finger's  theory  of  syphihs,  36. 
Fingers,  acquired  syphihs  of,  441. 
occurrence  of,  425. 

chancre  of,  238. 

hereditary  syphilis  of,  520. 
Fischer,  199. 

FLiJGEL,  28. 
Fordyce,  ix,  50. 
Formamidate  of  mercury,  175. 
Fournier,  a.,  53,  62,  88,  91,  94,  153, 
225,  241,  415,  458,  494,  502, 

504- 
Fournier,  E.,  75,  536. 
Foumier's  teeth,  536. 


Fourth  cranial  nerve,  paralysis  of,  388. 

Fox,  G.  H.,  ix,  301. 

Fracture,  non-union  of,  due  to  syphilis, 

433- 
spontaneous,  due  to  syphilis,  433. 
Fractures,  syphilis  of,  39. 
Fraenkel,  4S6. 
Framboesia  of  scalp,  312. 
Framboesia  tropica,  122. 
Frascatori,  12. 
Frauenthal,  447. 
French  method  of  treatment,  153. 
Frenum  eroded  by  chancroid,  214. 
Frequency.     See  Statistics  xxvii. 
Frontal  bone,  syphilis  of,  425,  439. 

hereditary,  520. 
Fumigation,  188. 
Functional  tachycardia,  485. 
Furuncular  hereditary  syphilid,  517. 

Galliot's  poifit,  176. 
Gangrene  of  chancre,  230. 

of  chancroid,  214. 
Gangrene  from  arterial  obstruction,  489. 

from  mercurial  injection,  184. 
Garnier  and  Lamoureux  granules,  170. 
Gastou,  492. 

Gastric  syphilis.     See  Stomach. 
Gastro-enteritis    from     Hver     syphiKs, 

474- 
Gaucher,  494. 
Gehrhardt,  466. 
Gengon,  22. 
Genital  organs,  chancre  of.  See  Chancre. 

chancroid  of.     See  Chancroid. 

secondary  lesions  of,  336. 
diagnosis  of,  345. 

tertiary  lesions  of,  476. 
Gerber,  367. 

German  method  of  treatment,  153. 
Giemsa  stain,  24. 
Girdle  sensation,  404. 
Glands.     See  Adenitis. 
Glans  penis,  chancre  of,  234. 

tertiary  lesions  of,  481. 
Glaucoma  in  hereditary  syphilis,  532. 
Glossitis,     sclerotic,     356.     See    also 
Tongue. 


INDEX 


553 


Glycosuria,  syphilitic,  492. 

Glycosuria  and  syphilis,  106. 

Goldhorn  stain,  25. 

GoLLMER,  134. 

Gonorriiea,  prevalence  of,  2. 

Gotha  Insurance  Co.  Statistics,  135. 

Grandhomme,  462. 

Grand  mal,  398. 

Gray  oil,  176. 

Gray  powder,  170. 

for  hereditary  syphiUs,  541. 
Green  color  of  syphilitic  crusts,  274. 
Green  iodid  of  mercury,  170. 
Grief,  a  cause  of  relapse,  39. 
Grosz,  177. 
Gum,  chancre  of,  237. 
Gumma,  differential  diagnosis  of,  from 
chancre,  245-246. 
of  arteries  of  brain,  374. 
Gumma,  diffuse,  pathology  of,  328. 
of  bone,  431. 

symptoms  of,  432-433. 
of  brain,  374. 
of  bronchi,  461. 
of  choroid,  421. 
of  ciliary  body,  421. 
of  conjunctiva,  422. 
of  esophagus,  492. 
of  glans  penis,  481. 
of  heart,  485. 
of  kidney,  499. 
of  larynx,  455. 
of  liver,  470. 
of  lung,  465. 

in  hereditary  syphilis,  466. 
of  lymph  nodes,  490. 
of  muscles,  448. 
of  nose,  363. 
of  palate,  363. 
of  pancreas,  492. 
of  penis.     See  Chancre  redux. 
of  pharynx,  359. 
of  salivary  glands,  492. 
of  sclera,  422. 
of  spinal  cord,  375. 
of  stomach,  493. 
of  tarsus,  423. 
of  tendon  sheaths,  451. 


Gumma  of  tongue,  356. 

of  tonsil,  358. 

of  trachea,  461. 

of  uveal  tract,  421. 

of  veins,  489. 

of  velum,  360. 

pathologic  diagnosis  of,  328. 

pathology  of,  327. 

pathology  of  diffuse,  328. 

relapses  of,  about  mouth,  351. 

subcutaneous,  327.     See  also  Subcu- 
taneous Gumma. 

treatment  of,  147. 
Gummatous  bursitis,  449. 
Gummatous  iritis,  412. 
Gummatous  syphilid,  hereditary,  517. 
Gummatous  ulcer,  331. 
Gums,  mercurial  ulceration  of,  163. 
Guttate  squamous  syphilid,  296. 

Habit  the  great  aid  in  treatment,  152. 
Habits  of  patient,  effect  of,  on  progno- 
sis, 129. 
Halberstaedter,  32. 
Ham  color  of  syphiHds,  273. 
Hannam's  biniodid  serum,  175. 
Hanzel,  461. 
Hastings,  376. 

Headache,    a   prodrome   of  syphilis   of 
nervous  system,  378. 
date  of  onset  of,  372. 
of  early  syphilis,  264. 
Heart,  gumma  of,  485. 

sclerosis  of,  485.  » 

syphilis  of,  484. 
secondary  lesions  of,  485. 
tertiary  lesions  of,  485. 
Hematology  of  early  syphilis,  254. 
Hematoporphyrinuria      in      hereditary 

syphilis,  527. 
Hemiplegia,  389.     See  also  Syphihs  of 
Nervous  System, 
association  of,  with  other  lesions,  390. 
bilateral,  391. 
clinical  type  of,  390. 

date  of  onset  of,  372. 
in  spinal  syphilis,  404. 
incompleteness  of,  390. 


554 


INDEX 


Hemiplegia,  onset  of,  389. 

prognosis  of,  394. 

var}dng  intensity  of,  390. 

mth  dementia,  400. 
Hemoglobinuria    in    acquired    syphilis, 
496. 

in  hereditary  syphilis,  527. 
Henderson,  486. 
Hennet,  367. 

Hepatic  syphilis.     See  Liver,  Syphilis  of. 
Hereditary  immunity,  42. 
Hereditary  infectiousness,  duration  of, 

16,  68,  95,  505. 
Hereditar}'  syphiKd,  acneiform,  512. 

ano-genital,  516. 

bullous,  513. 

condylomatous,  527. 

confluent,  512. 

distribution  of,  513. 

furuncular,  517. 

gummatous,  517. 

maculo-papular,  514. 

of  lips,  516. 

of  mucous  membranes,  517. 

of  scalp,  516. 

polymorphous,  512. 

pustular,  517. 

relapses  of,  527. 

treatment  of,  539,  541. 

tubercular,  517. 
Hereditary  syphilis,  16,  65,  504. 

and  atrophic  rhinitis,  367. 

and  rachitis,  524,  52S,  532,  538. 

and  tuberculosis,  524. 

anemia  pseudo-leukemia  in,  527. 

ano-genital  lesions  of,  516. 

aphonia  in,  518. 

ascites  in,  522. 

bronchopneumonia  in,  523. 

cause  of,  16,  65. 

condyloma  in,  527. 

cor\'za  of,  510. 
treatment  of,  541. 

dactylitis  in,  520. 

danger  of,  65. 

deafness  in,  523. 

decreasing  nocivity  of,  72. 

dental  stigmata  of,  534. 


Hereditarj-  syphiUs,  development  arrest- 
ed in,  525,  533. 
diagnosis  of,  537. 

by  history,  538. 

in  infancy,  537. 

in  later  years,  538. 

in  third  generation,  75. 
diffuse  periostitis  in,  529. 
divisions  of,  505. 
duration  of,  528. 
dystrophies  of,  525. 
epilepsy  in,  525. 
etiology  of,  16,  65. 
eye  lesions  of,  523. 
eye  stigmata  of,  536. 
fetal,  506. 
glaucoma  in,  532. 
gumma  in,  517. 
hematoporph}Tinuria  in,  527. 
hemiplegia  in,  527. 
hemoglobinuria  in,  527. 
hydrocele  in,  521. 
hydrocephalus  in,  523. 
idiocy  in,  525,  532,  538. 
in  third  generation,  75. 
in  infancy,  508. 
in  utero,  504. 

infantile  polymortality  in,  65,  504. 
infantilism  in,  525,  533. 
interstitial  keratitis  in,  531. 
iodid  of  potassium  for,  540,  541. 
jaundice  in,  522. 
late,  528. 

hp  erosions  of,  516. 
hver  in,  522. 
local  treatment  of,  541. 
lung  in,  462,  466. 
lymphadenitis  of,  521. 
meningitis  in,  523. 
mercury  for,  539. 
miscarriages  in,  65. 
mixed  infection  in,  523. 
mucous  membrane,  lesions  in,  517. 
nasal  deformity  in,  511. 
nasal  inflammation  in,  510. 
nerve  deafness  in,  523. 
nervous  system  involved  in,  522. 
ocular  lesions  of,  523. 


INDEX 


555 


Hererlitars'  svphilis,  ocular  stigmata  uf, 

536^ 
onycliia  in,  516. 
of  bone,  518. 
of  ear,  523. 
of  eye,  523. 
of  joints,  518,  521. 
of  lung,  lesions  of,  462. 

symptoms  of,  466. 
of  third  generation,  75. 
orchitis  of,  521. 

diagnosis  of,  521. 
osteochondritis  in,  518. 
osteoperiostitis  in,  529. 
otitis  media  in,  523. 
parenchymatous  keratitis  in,  531. 

treatment  of,  532. 
paronychia  of,  516. 
pathology  of,  506. 
pemphigus  in,  513. 

diagnosis  of,  514. 
periostitis  in,  520. 
polvTuorphous  lesions  of,  512. 
polymortality  of,  504,  539. 
prognosis  of,  539. 
pseudo-paralysis  in,  518. 
relapses  of,  in  early  childhood,  527. 

late,  528. 
restlessness  in,  522. 
routine  treatment  of,  540. 
scalp  lesions  of,  516. 
sepsis  in,  524. 
sleeplessness  in,  522. 
snuffles  in,  510. 

treatment  of,  541. 
spirochetas  in,  29. 
spleen  in,  522. 
stigmata  of,  532. 

auditory,  536. 

ocular,  536. 
stridor  thymicus  in,  527. 
symptoms  of,  507. 
theory  of,  69. 
treatment  of,  539. 

by  calomel,  541. 

by  gray  powder,  541. 

by  injections,  540,  541,  542. 

byiodids,  540,  541. 


Hereditary    syphilis,   treatment    of,    by 
mercurial  plaster,  540. 
condylomata  in,  541. 
erosions  in,  541. 
in  infancy,  539. 
late  relapses  of,  541. 
pustular  lesions  of,  541. 
snuffles  of,  541. 
Aiscera  inflammation  in,  521. 
Heredity,   syphilitic,    65.     See   also  In- 
heritance and  Hereditary  Syph- 
ilis, 
maternal  conceptional,  73. 
maternal  post-conceptional,  73. 
nocivity  of,  504. 
paternal,  67. 

arguments  against,  71. 
arguments  in  favor  of,  70. 
effect  of  treatment  on,  71. 
nocivit}'  of,  504. 
theor}'  of,  69. 
Hermophenyl,  175. 

Herpes,     buccal,     distinguished     from 
syphilis,  344. 
differential  diagnosis  of,-  from  chan- 
cre, 244-246. 
Herpetiform  chancre,  228. 

syphihd,  293. 
Heubner,  52,  373. 
Hill,  6. 
HlRSCH,  41,  199. 
History  of  syphilis,  12. 
hochsinger,  71,  504,  510,  522,  540. 
Hoffmann,  22,  31,  47. 
Holt,  516,  541. 
Hot  Springs  of  Arkansas,  142. 
method  of  inunction  at,  185. 
HowLAND,  504. 

HUGUENIN,   531. 

Humerus,  occurrence  of  syphilis  in,  425. 
Hunt,  28. 

HtJNTER,  12. 

Hurd,  336,  349,  452,  461. 

HUTCHLNTSON,  75,  53 1,  540. 
Hutchinson's  teeth,  534. 

triad,  533,  534. 
Hyde,  539. 
Hydrarthrosis,  syphilitic,  445. 


556 


INDEX 


Hydriodic  acid,  syrup  of,  199. 
Hydrocele,  480. 

in  hereditary  sypliiKs,  521. 
Hydrocephalus    in    hereditary    syphilis, 

523- 
Hygiene,  effect  of,  on  tertiary  relapses, 
102. 
of  syphilis,  140. 
of  hereditary  syphilis,  539. 
Hypertrophic  onychia,  310. 
Hypertrophic  papule.     See  Condyloma. 

Ichthyol  for  squamous  syphilid,  309. 
Idiocy  in  hereditary  syphiUs,  525,  532, 

538. 
Ilium,  occurrence  of  syphilis  in,  425. 
Immunity  to  syphilis,  41. 
by  heredity,  42. 
by  inoculation,  33. 
congenital,  125. 
of  Esquimaux,  41. 
of  negroes,  41. 
of  South  Sea  Islanders,  41. 
racial,  41. 
Impetiginous  syphilid,  295. 
Impetigo  contagiosa,  differentiated  from 

syphilis,  295. 
Improvement  in  treating  syphilis,  42. 
Incidence  of  syphilis,  age  of,  58. 
Incidence  of  tertiary   symptoms,   table 

of,  96. 
Incision    of    foreskin    in    treatment    of 
chancroids,  220. 
of  subcutaneous  gumma,  331. 
Incompleteness  of  hemiplegia,  390. 
Increase  of  spirocheta,  method  of,  47. 
Incubation,     primary     and    secondary, 

duration  of,  80. 
Incubation  of  chancroid,  210. 
Indurated  papule  chancre,  228. 
Indurations  from   mercurial  injections, 

183. 
Infantile  polymortality  in  syphilis,  65, 

504,  539- 
Infantile  syphilis,  509. 
Infantilism  in  hereditary  S3^hilis,  525, 

533- 
Infection,  duration  of,  61. 


Infection,  extragenital.     See  Extrageni- 
tal Infection, 
marital,  6,  61,  64. 
possibility  and  probability  of,  59, 
Infectiousness  of  blood,  23. 
of  chancroid,  208,  209. 
of  gumma,  36. 
of  late  secondary  lesions,  93. 
of  syphilis,  duration  of  hereditary,  505. 
table  showing,  68. 
Infiltration  of  face,  diffuse,  312. 
of  larynx,  453. 
of  palate,  363. 
Inflamed  chancroid,  213. 
Inflammation,  absence  of,  from  syphi- 
lids, 272. 
of  syphilitic  ulcer,  326. 
Inflammatory  paronychia,  310. 
Inheritance,  syphilitic,  65. 
Inherited      syphilis.     See      Hereditary 

Syphilis. 
Inguinal  adenitis  of  chancre,  239. 

of  chancroid,  214. 
Initial  lesion,  222.     See  also  Chancre. 

diagnosis  of,  120,  242. 
Injections   of   mercury.     See   Mercury, 

Injections  of. 
Inoculation,  immunity  from,  7,^. 
of   syphiKs  on  animals,  30. 
subcutaneous,  32. 
Insanity,  syphilitic,  398. 
prodromes  of,  399. 
prognosis  of,  402. 
Insoluble    injections    of   mercury.     See 

Mercury,  Injections  of. 
Instructions  to  syphilitic  patients,  155. 
Itching,  absence  of,  from  syphilids,  272. 
Intellectual  distiurbances  preceding  syph- 
ilis of  nervous  system,  379. 
Intermissions    in    internal    administra- 
tions of  mercury,  173. 
in  tonic  treatment  of  syphilis,  157. 
Intermittent  claudication,  489. 
Intermittent  treatment  of  syphilis,  152. 
of  syphilis  of  nervous  system,    148, 

383- 
Internal     administration     of    mercury, 
169,  170. 


INDEX 


557 


Internal  ophthalmoplegia,  388. 

Interstitial  keratitis,  531. 

Interstitial  myositis,  448. 

Interstitial  sypliilitic  pneumonia,  464. 

Intervals  between  tertiary  relapses,  98. 

Intestines,  syphilis  of,  493, 

Intramuscular    injection    of    mercury. 

See  Mercury,  Injections  of. 
Intratracheal  injection  of  mercury,  190. 
Intubation  for  tracheal  syphilis,  461. 
Inunction  of  mercury,  185. 

in  hereditary  syphilis,  540. 
Iodic  acne,  194. 

differentiated  from  syphilis,  295. 
Iodic  albuminuria,  195. 
Iodic  bullae,  194. 
Iodic  coryza,  193. 
Iodic  dermatitis,  194. 
Iodic  edema,  195. 
Iodic  cpistaxis,  195. 
Iodic  grippe,  193. 
Iodic  indigestion,  194. 
Iodic  neuralgia,  195. 
Iodic  purpura,  194. 
Iodic  salivation,  195. 
Iodic  toxemia,  194. 
Iodic  urethritis,  195. 
lodid  of  ammonium,  199. 
lodid  of  calcium,  199. 
lodid  of  potassium.     See  also  lodids. 

dose  of,  200. 
lodid  of  sodium,  199. 
lodid  of  starch,  199. 
lodid  of  strontium,  199. 
lodid  poisoning,  192. 
lodids,  192. 

administration  of,  195. 

dosage  of,  195. 

dilution  of,  197. 

do  not  prevent  relapses,  145. 

dangerous,  in  pulmonary  syphilis,  468. 

duration  of  treatment  with,  201. 
for  hereditary  syphihs,  540,  541. 

for  osteocopic  pains,  264. 

in  treatment  of  syphilids,  277. 

of  syphilis  of  nervous  system,  383. 

saturated  solution  of,  195. 

therapeutic  indications  for,  192. 


lodin,  tincture  of,  199. 
lodipin,  200. 
lodism,  192. 

prevention  of,  197. 
Iodoform  for  chancroid,  219. 

for  syphihs,  199. 
lothion,  199. 
Irido-choroiditis,  418. 
Iritis,  syphilitic,  411. 

bilateral,  411. 

complications  of,  414. 

condylomatous,  412. 

diagnosis  of,  414. 

etiology  of,  411. 

frequency  of,  411. 

gummatous,  412. 

pathology  of,  412. 

plastic,  412. 

prognosis  of,  415. 

symptoms  of,  412. 

treatment  of,  415. 
Iron  and  mercury,  171. 
Israel,  500. 
istamanoff,  207. 
Italian  method  of  treatment,  153. 

Jacksonian  epilepsy,  398. 
JACQUET,  509,  517. 
Jacquin,  465. 

JAENSELINE,   122. 

Janeway,  269. 

Jaundice  in  early  syphilis,  265. 

in  hereditary  syphilis,  522. 

in  tertiary  liver  syphilis,  474. 
Jaw.     See  Maxilla,  Mandible. 
Joints,  syphilis  of,  444. 

hereditary,  518,  521. 
JULLIEN,  75. 
Justus's  test  for  syphihs,  116. 

Kaevonen,  495. 
Kassowitz,  74. 
Keratitis,  interstitial,  531. 

punctate,  412. 
Kidney,  syphihs  of,  495. 

diagnosis  of,  498,  500. 

sclero-gummatous,  499. 

treatment  of,  498. 


558 


INDEX 


Kissing   a    cause    of    chancre    of    ton- 
sil, 56. 
a  cause  of  syphilis,  55. 
Klemperer,  269. 
Klieneberger,  179. 
Klotz,  489. 

Knee-jerk  in  spinal  syphilis,  403. 
Knee-jerk  lost  in  tabes,  no. 
KoNiG,  477. 
KosTER,  373. 

KOKAWA,  462. 

Krafft-Ebing,  107. 
Kraus,  27. 
Krefting,  55. 
Kretling,  207. 

Labbe,  457. 

Lacrymal  glands,  syphilis  of,  423. 

Lacrymo-nasal  duct,  syphilis  of,  423. 

Lancereaitx,  492. 

Lancret,  207. 

Landis,  190. 

Lang,  43,  80,  377. 

Lang's  theory  of  syphilis,  36. 

Landsberg,  161. 

Larrier,  22. 

Lar}'nx,  syphilis  of,  452. 

aphonia  due  to,  454. 

condylomatous,  453. 

erythematous,  453. 

etiology  of,  452. 

fibroid  degeneration  in,  455. 

gummatous,  455. 

infiltration  from,  453. 

macular,  453. 

papular,  453.     . 

paralysis  from,  457. 
date  of  onset  of,  372. 

perichondritis  from,  456. 

prognosis  of,  459. 

secondary,  lesions  of,  452. 
diagnosis  of,  454,  458. 
treatment  of,  454. 

tertiary,  lesions  of,  454. 

'    diagnosis  of,  458. 
s}'mptoms  of,  457. 
treatment  of,  459. 

tracheotomy  for,  460. 


Lar}^nx,  sj'philis  of,  treatment  of,  459. 
ulceration  from,  453. 

LASNET,'207. 

Late  hereditary  syphilis,  528. 

Late  infection  with  syphilis,  62. 

Late  infectious  secondary  lesions,  effect 

of  tobacco  on,  95. 
Late  lesions,  incidence  of,  104. 
Late  relapses,  diagnosis  of,  121. 

of  hereditary    syphilis.     See  Heredi- 
tary Syphilis. 
Late  secondary  lesions,  87. 

infectiousness  of,  93. 
.    prevention  of,  94. 

regions  involved  by,  92. 
Lateral  incision  of  foreskin,  220. 
Law,  Colles's,  16,  70. 

Profeta's,  74. 
Ledermann,  165. 
Le  Fur,  501. 

Leg  ulcer,  differential  diagnosis  of,  334. 
Lenticular  papular  syphilid,  290. 
Leontiasis,  351. 
Le  Pileur,  505. 
Leprosy  differentiated  from  syphilis,  300, 

327- 
Lesion,    primary.     See    Chancre,    Pri- 
mary Lesion. 
Lesions  of  capillaries  in  syphilis,  48. 

of  the  larger  vessels,  51. 

of  smaller  vessels,  49. 
Lesions  of  syphilis,  pathology  of.     See 
Pathology. 

secondary.     See  Secondary  Lesions. 

tertiary.     See  Tertiary  Lesions. 

treatment  of.     See  Treatment. 
Leukocytosis  of  early  syphilis,  255. 
Leukoplakia,  352. 

characteristics  of,  353. 

diagnosis  of,  354. 

etiology  of,  352. 

influence  of  tobacco  on,  350. 

prognosis  of,  354. 

relapses  of,  350. 

statistics  of,  350. 

treatment  of,  355. 

and  epithelioma,  355. 
Levaditi,  22,  28,  53. 


INDEX 


559 


Levaditi  stain,  25. 
Levy-Bing,  180. 

Lichen  planus  differentiated  from  pap- 
ular syphilid,  291. 
Life  insurance  in  syphilis,  133. 
Lip,  chancre  of,  237. 

erosions    of,    in    hereditary    syphilis, 
516. 
infiltration  of,  312. 
tertiary  syphilis  of,  351. 

differential  diagnosis  of,  249. 
Lip    epithelioma,    differential  diagnosis 
of,  249. 
scars    pathognomonic    of    hereditary 
syphilis,  532. 
Lipiodol,  200. 
LiPSCHUTZ,  199. 
Liver,  syphilis  of,  469. 
ascites  due  to,  473. 
cachectic  type  of,  476. 
cachexia  from,  474. 
cirrhotic  type  of,  475. 
complications  of,  472. 
diagnosis  of,  474-476. 
etiology  of,  469. 
febrile  type  of,  476. 
gastro-enteritis  in,  474. 
gumma  of,  470'. 
hereditary,  506,  522. 
jaundice  in  early,  265. 
in  hereditary,  522. 
in  tertiary,  474. 
neoplastic  type  of,  473. 
pain  from,  473. 
pathology  of  secondary,  470. 
pathology  of  tertiary,  470. 
pathology  of  hereditary,  470,  506. 
prognosis  of,  477. 

portal  circulation  impeded  in,  474. 
sclerosis  of,  470. 
secondary,  265. 
spleen  enlarged  with,  474. 

with  hereditary,  522. 
symptoms  of,  473. 
hereditary,  522. 
tertiary,  469. 
treatment  of,  477. 
types  of  acquired,  476. 


Livingstone,  41. 

Local  symptoms  of  secondary  toxemia, 

Local  treatment  of  bone  syphilis,  437. 
of  chancre,  233. 
of  chancroid,  217. 
of  chorio-retinitis,  419. 
of  condyloma,  346. 
of  erosive  syphilid,  346. 
of  hereditary  syphilis,  541. 
of  iritis,  415. 

of  laryngeal  syphilis,  459. 
of  leukoplakia,  355. 
of  mucous  papules,  346. 
of  parenchymatous  keratitis,  532. 
of  paronychia,  311. 
of  subcutaneous  gumma,  335. 
of  syphilis,  150. 
of  tracheal  syphilis,  461. 
of  ulcer,  327,  335. 
Locomotor  ataxia.     See  Tabes. 
Loss  of  weight  from  syphilis,  259. 
Lower  jaw.     See  Mandible. 
Luc,  458. 

Lung,  gumma  of,  465. 
syphilis  of,  460. 

bronchiectasis  in,  465. 
broncho-pneumonic  type  of,  467. 
complications  of,  465. 
diagnosis  of,  468. 
mixed  infection  in,  465. 
pathology  of,  464. 
hereditary,  462. 
pseudo-tubercular  type  of,  467. 
sclerosis  of,  464. 
silent  type  of,  467. 
statistics  of,  460. 
symptoms  of,  467. 
hereditary,  466. 
tracheal  type  of,  467. 
treatment  of,  468. 
Lupus    differentiated    from    tubercular 
syphilid,  317. 
from  ulcerative  syphilid,  327. 
Lymph  nodes.     See  Adenitis. 

spirochetas  in,  28. 
Lymphangitis  of  chancre,  228. 
of  chancroid,  214. 


560 


INDEX 


L-\-mphocvtosis   of  cerebro-spinal   fluid, 
376. 

mcdoxxell,  144. 
Mackenzie,  366,  455,  460,  461. 
Macular  syphilid,  281. 

character  of,  283. 

circinate,  284. 

diagnosis  of,  286. 

differential  diagnosis  of,  286. 

duration  of,  285. 

elevated,  284. 

late,  284. 

of  hereditary  syphilis,  512. 

of  larv-nx,  453. 

of  mucous  membranes,  337. 

regions  involved  by,  28 1. 

A'arieties  of,  284. 
Macule,  pathologj'  of,  278. 
Malar  bone,  occurrence  of  syphilis  in, 
425. 

M.AXHERBE,    251. 

MaKgnant  early  s}-philis,  19. 

Malignant  late  syphilis,  21. 

Man,  absence  of  primary-  lesion  in,  45, 

83. 

absence  of  secondary  outbreak  in,  83, 
126. 
ZMandible,  syphilis  of,  442. 

occurrence  of,  425. 
Mania,  s}'philitic,  399. 

date  of  onset  of,  372. 
Mannaberg,  269. 
Marcus,  190. 
Margotjlies,  501. 
Marie,  47,  109. 
Marino  stain,  25. 
Marriage,  when  permissible,  63. 
Marriage  and  syphiUs,  4,  61. 

moral  aspects  of,  64. 
[Marital  infection,  duration  of,  6. 

instant  danger  of,  62. 
Marshall,  352. 
Martin,  Edward,  214. 
Massed  tubercular  syphilid,  314. 
Maternal  coticeptional  heredity,  73. 
Maternal  post-conceptional  heredity,  73. 
Maternity  and  syphilis,  65. 


Matzenauer,  69. 

Mauriac,  498. 

Maxilla,  occurrence  of  syphihs  in,  425. 

Mayer,  199. 

Measles    differentiated    from    macular 

syphilid,  286. 
Mediate  infection  with  syphilis,  32. 
Mendel,  489. 
Meningeal  lesions,  374. 
^Meningitis,  a  cause  of  ocular  paralysis, 

389- 
basilar  sjTnptoms  due  to,  382. 
cerebral  syphilitic,  374. 
early  secondary,  377. 
prognosis  of,  378. 
treatment  of,  378. 
in  hereditary  s^-philis,  523. 
syphilitic  spinal,  375,  406. 
IMercurial  dermatitis,  166. 
ISIercurial  diarrhea,  165. 
Mercurial  entero-colitis,  165. 
Mercurial  nephritis,  165. 
Mercurial  salivation,  162. 
Mercurial  shirt,  1S6. 
Mercurial  stomatitis,  162. 

diagnosis  of,  343. 
Mercur}',  absorption  of,  161. 
administration  of,  169. 
and  cinchona,  172. 
and  iron,  171. 
beneficial  effects  of,  161. 
benzoate  of,  175. 
bichlorid  of,  171,  174. 
biniodid  of,  170,  175. 
comparison   of  methods  of  adminis- 
tering, 169,  191. 
contraindications  to  use  of,  167. 
effect  of,  on  hemoglobin,  255. 
on  leucocytosis,  255. 
on  red  cells,  255. 
on  relapses,  102,  131. 
elimination  of,  161. 
fumigation  with,  188. 
in  prophylaxis,  33. 
in  treatment  of  various  lesions.     See 

Treatment, 
in   treatment   of  hereditary   s}'philis, 

539- 


INDEX 


561 


Mercur}',  injections  of,  174. 

advantages  of,  180,  184. 

benzoate,  175. 

bjchlorid,  174. 

biniodid,  175. 

calomel,  176. 

comparative  merits  of,  169,  iSo. 

disadvantages  of,  181. 

dosage  of,  178. 

embolism  from,  178,  182. 

enesol,  175. 

for    various    lesions.     See    Treat- 
ment. 

formamidate,  175. 

frequency  of,  179. 

gangrene  from,  184. 

indurations  from,  183. 

gray  oil,  176. 

insoluble,  174. 

method  of,  176. 

oxycyanid,  175. 

pain  from,  180-182. 

poisoning  by,  179. 

salicylate,  175. 

salivation  from,  179. 
internal  administration  of,  169-170. 

how  to  begin,  172. 

intermissions  in,  173. 

merits  of,  173. 

minimum  dose  in,  173. 
intramuscular      injections      of.     See 

Mercury,  Injections  of. 
intratracheal  injection  of,  190. 
inunction  of,  185. 

duration  of,  1S7. 

merits  of,  187. 

technic  of,  185. 
intravenous  injection  of,  189. 
method  of  administering,  154. 
minimum  dose  of,  173. 
not  a  cause  of  bone  syphilis,  427. 
opium  not  to  be  used  with,  172. 
physiological  effects  of,  161. 
pill  of,  171. 
plaster  of,  185. 
poisoning  by,  chronic,  166. 
protiodid  of,  170. 
rectal  injection  of,  190. 


Mercury,  relapses  of  sypliilis  prevented 

by,  145- 
salivation  by,  162. 

soluble   injections  of.     See  Mercury, 
Injections  of. 

tannate,  171. 

tonic,  effect  of,  145. 

toxicology  of,  162. 

use  of,  in  nephritis,  168,  498. 
in  tuberculosis,  167. 
Mering,  199. 
Merzbacher,  376. 
Metchnikoff,  22,  31,  32. 
Metacarpus,  occurrence  of   syphilis  in, 

425- 
Metatarsus,    occurrence   of  syphilis  in, 

425- 
Method  of  administering  iodids,  195. 
mercury  internally,  154,  169. 

of  fumigating,  188. 

of  injecting  mercury,  176. 

of  inunctions,  186. 
Metrorrhagia,  syphilitic,  503. 
Michel,  531. 
Middleton,  411. 
Middle  ear,  syphilis  of,  348. 
Mild  but  persistent  syphilis,  20. 
Mild  early  syphilis,  18. 
Mild  late  syphihs,  21. 
MiLIAN,  462. 

Miliary  papular  syphilids,  290. 
Minim  drop,  196. 
Minimum  dose  of  mercury,  theorj'  of, 

173- 
Miscarriage  in  hereditary  syphilis,   65, 

506,  507,  539. 
Mixed  infection  in  hereditary  syphilis, 

523- 
Mixed  sore,  213,  229. 
Mixed  treatment,  202. 
Mobility  of  spirocheta,  23. 
Modern  interrupted  method  of  treating 

syphilis,  153. 
Moist  papule.     See  Mucous  Papule. 
Monkeys,  syphilis  in,  31. 
Monoplegia,  date  of  onset  of,  372. 
Monoplegia  in  spinal  syphihs,  404. 
Montgomery,  55. 


562 


INDEX 


Moral  aspects  of  marriage  and  syphilis, 

64. 
Moral   disturbances   preceding   syphilis 

of  nervous  system,  379. 
Morbid  Anatomy.     See  Pathology. 
Morgan,  493. 
Morrow,  293,  313. 
MortaUty  of  syphihs,  135. 
Motor  ocuH,  387. 
Mouth,  aphthous  erosions  of,  344. 

chancre  of,  249. 

concurrence  of  tertiary  lesions  in,  351. 

diagnosis  of,  343. 

erosions  in,  337. 
treatment  of,  346. 

gummata  in  relapses  of,  351. 

herpes  of,  344. 

mucous  papules  of,  337. 

tertiary  syphilis  of,  349. 

ulcers  of,  secondary,  diagnosis  of,  342, 

343- 
tertiary,  349. 
Mucous  membrane,  condyloma  of.     See 
Condyloma, 
lesions  of,  in  hereditary  syphilis,  517. 
macular  syphilid  of,  337. 
papule  of.     See  Mucous  Papule. 

hypertrophic.     See  Condyloma, 
secondary  lesions  of,  336. 
tertiary  lesions  of,  349. 
ulcers  of,  342. 
Mucous  papules,  337. 
diagnosis  of,  343. 
in  hereditary  syphilis,  5 1 6-5 1 7. 
of  conjunctiva,  422. 
of  female  genitals,   differential  diag- 
nosis of,  345. 
of  larynx,  453. 
of  skin,  302. 
of  trachea,  460. 
symptoms  of,  338. 
treatment  of,  346. 
Mucous  patch.     See  Mucous  Papule. 
Multiple  chancre,  224. 
MuLZER,  27. 

Muscle,    hematoma    of,    in    hereditary 
syphilis,  521. 
gumma  of,  448. 


Muscle,  gumma  of,  in  hereditary  syph- 
ilis, 521. 

syphilis  of,  447. 
hereditary,  521. 
Muscle  contracture,  448. 
Myelitis,  syphilitic,  406. 
Myocarditis,  syphilitic,  485. 
Myosalgia,  264. 
Myositis,  gummatous,  448. 

interstitial,  448. 
Myositis  ossificans,  449. 
Myringotomy,  348. 

Nageotte,  376. 

Nasal  septum,  gumma  of,  364.     See  also 

Nose. 
Natiform  skull,  520. 
Nature  of  syphilis,  35. 
Negro's  immunity  to  syphilis,  41. 
Neisser,  25,  32. 

Neoplasm  differentiated  from  syphilis, 
328. 
from  syphilis  of  bone,  437. 
of  intestine,  493. 
of  kidney,  500. 
of  larynx,  458. 
of  lip,  249. 
of  liver,  473. 
of  rectum,  494. 
of  skin,  333. 
of  stomach,  493. 
of  testicle,  481. 
of  tongue,  357. 
Neoplastic  type  of  liver  syphihs,  473. 
Nephritis,  mercurial,  165. 

occurrence  of,  in  syphilis,  497.    . 
sclero-gummatous,  499. 

diagnosis  of,  500. 
syphilitic,  495. 
use  of  mercury  in,  168. 
Nerve  deafness,  395. 

in  hereditary  syphihs,  523. 
Nerves,  syphilis  of,  408. 
Nervous    symptoms    of    early    syphilis, 

260. 
Nervous  system,  syphilis  of,  368. 
aphasia  a  prodrome  of,  380. 
clinical  types  of,  386. 


INDEX 


563 


Nervous  system,  syphilis  of,  convulsive 
prodromes  of,  uncommon,  3S0. 
course  of,  ^Si. 
diagnosis  of,  408. 
effect  of  age  on,  369. 

of  alcohol  on,  370. 

of  civilization  on,  370. 

of  early  treatment  on,  369. 

of  race  on,  368. 

of  sex  on,  369. 
etiology  of,  368. 
hereditary,  522. 
impairment    of    sexual    power    in, 

379- 
intellectual  disturbances  preceding, 

379- 

irregularity  of,  409. 

moral  disturbances  preceding,  379. 

occurrence  of,  371. 

onset  of,  371,  381. 

paralytic  prodromes  of,  380. 

pathognomonic  types  of,  410. 

pathologic  diagnosis  of,  382. 

pathology  of,  373. 

prodromes  of,  378. 
duration  of,  381. 

prognosis  of,  382. 

symptoms  of,  378. 

treatment  of,  14S,  383. 
neglected,  385. 

vertigo  a  prodrome  of,  380. 
Neumann,  35,  62. 
Neuralgia,  iodic,  195. 

syphilitic,  372. 
Neurasthenia  and  syphilis,  106. 
Neuritis,  408. 

optic,  388,  419. 
Neuro-retinitis,  420. 
Newborn,  pneumonia  of,  462. 
Nicolas,  27. 

NiCOLSKY,  184. 
NiTZE,  32. 

Nocturnal    exacerbations   of   headache, 
378. 

NOKGGERATH,   28. 
NOGUKS,  502. 

Non-union  of  fracture  due  to  syphilis, 

433- 
38 


Nose,    deformity    of,    due    to    acquired 
syphilis,  365. 
due  to  hereditary  syphilis,  511. 
gumma  of,  363. 
diagnosis  of,  366. 
symptoms  of,  364. 
treatment  of,  366. 
inflammation  of,  in  hereditary  syph- 
ilis, 510. 
lesions  of,  statistics  of,  350. 
saddle-backed,  365. 
syphiloma  of,  366. 
tertiary  lesions  of,  363. 
ulceration  of,  363. 
Nosophen  for  chancroids,  219. 

NOYES,  415. 

Number  of  chancres,  225. 

of  syphilitic  children,  table  of,  67. 
Numbness  in  spinal  syphilis,  404. 
Nummular  syphilid,  290. 

Obstruction  of  arteries  of  extremities, 

489. 
Obturator  for  perforation  of  palate  or 

velum,  362. 
Occipital  bone,   occurrence  of  syphilis 

in,  425. 
Occult  syphilis  in  women,  16,  45,  79. 
Occurrence  of  various  lesions.     See  Sta- 
tistics. 
Ocular  lesions.     See  Eye. 
"  Olympian  "  brow,  520. 
Onset  of  hereditary  syphilis,  507. 

of  syphilis  in  man,  78. 

of  syphilis  in  woman,  79. 

of  syphilis  of  nervous  system,  371. 
Onychia,  atrophic,  309. 

detachment  of  nail  in,  310. 

hypertropliic,  310. 

of  hereditary  syphilis,  516. 

treatment  of,  311. 

ulcerative,  310. 
Onyxis  craquele,  309. 
Operative   treatment  of  bone   sypliilis, 

_43S. 
of  brain  syphilis,  3S5. 
of  kidney  syphilis,  500. 
of  liver  syphilis,  477. 


5^4 


INDEX 


Operative   treatment    of    subcutaneous 

gumma,  335. 
Opium  not  to  be  used  with  mercurj% 

172. 
Oppenheim,  27. 
Ophthalmoplegia,  internal,  388. 
Optic  ner\'e,  419. 

atrophy  of,  420. 
Optic  neuritis,  388. 

diagnosis  of,  421. 

pathology  of,  419. 

S3miptoms  of,  421. 

treatment  of,  421. 
Orbital  syphilis,  423. 

nerve  symptoms  due  to,  388. 
Oriental  syphiHs,  severity  of,  41. 
Ossification  of  syphihtic  muscle,  449. 
Osteocopic  pains,  263,  433. 
Osteomyehtis,    differentiation    of,    from 
syphiKs,  436. 

syphihtic,  431. 
gummatous,  432, 
symptoms  of,  433. 
Osteoperiostitis,  428. 

gummatous,  431. 

in  hereditary  syphihs,  529. 

prognosis  of,  431. 

symptoms  of,  433. 
Otitis  media,  syphihtic,  348. 

hereditary,  523. 
Oxycyanidof  mercury  for  injection,  175. 

for  intravenous  injection,  189. 
Ovaries,  syphiHs  of,  503. 

Pain  from  injections  of  mercury,   180- 
182. 
from  liver  syphilis,  473. 
Pain  and  itching,  absence  of,  in  syphi- 

Hds,  272. 
Palate,  gumma  of,  363. 
infiltration  of,  363. 
perforation  of,  363. 
tertiary  lesions  of,  363. 
statistics  of,  350. 
treatment  of,  363. 
ulceration  of,  363. 
Palms  and  soles,   eczema  of,   differen- 
tiated from  syphilis,  308. 


Palms  and  soles,  psoriasis  of,  differenti- 
ated from  syphihs,  308. 
squamous  syphihd  of,  303. 
chagnosis  of,  308. 
treatment  of,  309. 
Panas,  421. 

Pancreas,  syphiUsof,  492. 
Papagaey,  224. 
Papillae  of  base  of  tongue  atrophied  in 

syphihs,  119. 
PapilHtis,  420. 
Papular  syphilid,  287. 
confluent,  287. 
diagnosis  of,  291. 
differential  diagnosis  of,  291. 
diffuse  induration  from,  291. 
disseminated,  289. 

erosive  or  moist.    See  Mucous  Papule, 
lenticular,  290. 
miliary,  290. 
nummular,  290. 
of  mucous  membranes.     See  Mucous 

Papule, 
scale  of,  288. 
varieties  of,  289. 
Papules,    hypertrophic.        See    Condy- 
loma, 
mucous.     See  Mucous  Papule, 
of  conjunctiva,  422. 
of  hereditary  syphihs,  512. 
of  larynx,  453. 
pathology  of,  278. 
vegetating.     See  Condyloma. 
Papulo-macular  syphilid,  284. 
Papulo-pustular    syphihd.     See   Pustu- 
lar Syphihd. 
Papulo-squamous  syphihd.      See  Squa- 
mous Syphihd. 
Paralysis,  acute  bulbar,  397. 
facial,  397. 
of  larynx,  457. 
of  ocular  nerves,  386. 

prognosis  of,  389. 
with  dementia,  400. 
Paralytic    prodromes     of     syphihs     of 

nervous  system,  380. 
Paraphimosis,  221. 
Paraplegia,  syphilitic,  406. 


INDEX 


565 


Paraplegia  in  spinal  syphilis,  404. 
Parasitic   eruptions   differentiated   from 

macular  syphilid,  286. 
Parasyphilids,  14,  105. 
cause  of,  40. 
definition  of,  105. 
infrequent  in  women,  45. 
varieties  of,  105. 
Parchment  chancre,  226. 
Parenchymatous    keratitis    in    acquired 
syphilis,  422. 
in  hereditary  syphilis,  531. 
treatment  of,  532. 
Paresis,  date  of  onset  of,  372. 
diagnosis  of,  100. 

by  lymphocytosis  of  cerebro-spinal 
fluid,  376. 
patholog}'  of,  log. 
prognosis  of,  iii. 
relation  of,  to  syphilis,  108. 
treatment  of,  iii. 
Paresthesia  in  spinal  syphilis,  404. 
Parietal  bone,  syphiKs  of,  439. 

occurrence  of,  425. 
Paeinaud,  531. 
Paronychia,  310. 
inflammatorv',  310. 
of  hereditary  syphilis,  516. 
squamous,  310. 
treatment  of,  311. 
tdcerating,  311. 
Paerott,  524. 
Parrott's  nodes,  520. 
Patella,  occurrence  of  syphiKs  in,  425. 
Paternal  syphihtic  heredity,  70. 
arguments  against,  71. 
arguments  in  favor  of,  70. 
Pathologic  diagnosis  of  gumma,  32S. 
of  syphilis  of  nervous  system,  382. 
Pathology  of  gumma,  diffuse,  328. 
of  internal  organs,  328. 
subcutaneous,  327. 
of  hereditary  syphilis,  506. 
of  paresis,  109. 
of  syphilis,  46. 

of  syphilis  of  nervous  system,  373. 
of  tabes,  109-. 
Patient,  instructions  to  syphilitic,  155. 


Patient's  condition  a  cause  of  relapse, 

39- 
Pelvic  cellulitis,  s}-phihtic,  502. 
Pehac  organs,  syphilis  of,  501. 
Pemphigus    neonatorum    differentiated 

from  hereditary  syphiHs,  514. 
Pemphigus  of  hereditary  syphilis,  513. 
Perforation  of  palate,  363. 
Peribronchial  adenitis,  461. 
Pericarditis,  486. 

Perichondritis,  syphihtic  larjmgeal,  456. 
Perihepatitis,  symptoms  of,  473. 
Period  of  calm,  diagnosis  of  syphihs  in, 

120. 
Periods  of  sypliilis,  15. 
Periostitis.     See  Osteoperiostitis. 
Perlia,  418. 
PermissibiUty  of  marriage  in  syphilis, 

63. 
Persistence  of  spirocheta,  37. 
Petit  mal,  398. 
Petresco,  28. 
Pfender,  23. 
Phagedena  in  chancre,  230. 

in  chancroid,  214. 
treatment  of,  221. 

tertiar}',  320. 
of  tonsils,  359. 
onset  of,  326. 
treatment  of,  322. 
Phagocytosis  of  spirocheta,  30. 
Phalanges,  syphihs  of,  441. 
Pharynx,  gumma  of,  359. 

secondary  syphilis  of,  336. 

tertiary  syphihs  of,  statistics  of,  350. 

ulceration  of,  359. 
Phimosis,  comphcating  chancroid,  213. 
Phlebitis,  syphilitic,  4S9. 
Phthisis  differentiated  from  pulmonary 

syphilis,  468. 
Physiological  effect  of  mercurj',  161. 
Pigmentary  retinitis,  417. 
Pigmentary  syphilid,  300. 

diagnosis  of,  300. 
Pigmentation  of  syphilids,  275. 
Pix  hquida  for  squamous  syphiUd,  309. 
Plastic  iritis,  412. 
Pleiad  of  Ricord,  239. 


566 


INDEX 


Pleurodynia,  264. 

occurrence  of,  87. 
Pneumonia,  syphilitic,  462. 
desquamative,  464. 
interstitial,  464. 
Poisoning,  iodic,  192. 

mercurial,  162. 
PolycycKc  shape  of  buccal  herpes,  344. 

of  genital  herpes,  245. 

of  syphilids,  273. 
Polymorphism,  272. 

of  hereditary  syphilids,  512. 
Polymorphous  eruption,  284^ 
Polymortality  in  hereditary  syphiKs,  65, 

504,  539- 
Portal     circulation    impeded    in     hver 

syphihs,  474. 
Possibility  of  infection  with  syphilis,  59. 
Potassiimi  iodid.     See  lodids. 
Potter,  119. 

Pott's  disease  imitated  by  syphilis,  443. 
Prautschoff,  27. 
Prevalence  of  gonorrhea,  2. 

of  syphilis,  2.  ' 

in  army,  3. 
Prevention.     See  Prophylaxis. 
Primary  incubation,  duration,  of,  80. 
Primary  lesion,  14.     See  also  Chancre, 
absent  in  men,  45. 
absent  in  women,  45. 
spirocheta  in,  28. 
Principles  of  prophylaxis  of  syphilis,  8. 

of  treatment  of  syphilis,  138. 
Probability  of  infection  with  syphilis,  59. 
Profeta's  law,  74. 
Prognosis  of  syphilis,  124. 
hereditary,  539. 
of  various   lesions.     See   regions   in- 
volved. 
Progressive    dementia    with     paratysis, 

400. 
Prophylaxis  of  late  secondary  lesions,  94. 
of  syphihs,  32. 

by  cauterization,  6,  ^^. 
by  excision  of  chancre,  ^^. 
by  mercury,  33. 
of  syphilis  of  nervous  system,  370. 
of  tertiary  lesions,  loi. 


Propriety  of  treating  uncertain  syphilis, 

159- 
Prostate,  syphilis  of,  502.. 
Prostitution  cannot  be  suppressed,  7. 
Protiodid  of  mercury,  170. 
Pseudo-syphiHtic  rheumatism,  445. 
Pseudo-tabes,  no. 
Psoriasis,    differentiated    from   syphilis, 

299. 
of  palms,  differentiated  from  syphilis, 

308. 
Ptosis  due  to  paralysis  of  motor  oculi, 

387- 
PubHc  health,  syphilis  in  relation  to,  i. 
Pulmonary  syphilis.     See  Lung,  Syphi- 
hs of. 
Punctate  keratitis,  412. 
Pupillary  abnormahty  a  sign  of  paresis, 

no. 
Pupillary  abnormality  in  spinal  syphilis, 
405.  ■ 
in  tabes,  no. 
Purpura,  iodic,   194. 
PusEY,  422. 
Pustular  syphilid,  292. 
acneiform,  293. 
ecthymatous,  296. 
hereditary,  517. 

treatment  of,  541. 
herpetiform,  293. 
impetiginous,  295. 
of  scalp,  311. 
varicelloid,  293. 
Pustule,  pathology  of,  279. 

Quaternary  syphihs,  n. 
Queyrat,  225. 

Rachitis   and  hereditary   syphilis,   524, 

528,  532,  538- 
Racial  immunity  to  parasyphilids,  107. 

to  syphihs,  41. 

to  syphihs  of  nervous  system,  368. 
Radiographs,  427,  428,  429,  432,  519. 
Radius,  occurrence  of  syphilis  in,  425. 
Ramon  y  Cajal,  25. 
Rare  secondary  lesions,  occurrence  of, 
87. 


INDEX 


567 


Ratjbitschek,  269. 
Ravosini,  199. 
Raymond,  461. 
Raynaud's  disease,  489. 
Rectal  chancre,  238. 
Rectal  injection  of  mercury,  190. 
Rectal  stricture,  495. 
Rectal  syphilis,  494. 
Red  blood  cells  in  early  syphilis,  254. 
Reflex  iridoplegia,  405. 
Reflexes,  disturbance  of,  in  spinal  syph- 
ilis, 403. 
Regions  involved    by  late    secondaries, 
92. 
involved  by  tertiary  relapses,  103. 
Reglementation,  futiUty  of,  7. 
Reinduration  of  chancre,  233. 
Reinoculation  v^^ith  syphilis,  32. 
Relapse  caused  by  alcohol,  103,  129. 
by  grief,  39. 

by  patient's  condition,  39,  125. 
by  tobacco,  39,  94,  130. 
by  trauma,  38,  129. 
of  hereditary  syphilis  in  early  child- 
hood, 527. 
later,  529. 
treatment  of,  541. 
of  secondary  lesions,  86. 
of  tertiary  lesions,  97.     See  also  Ter- 
tiary Relapse, 
of  various   lesions.     See   regions   in- 
volved, 
tonic  treatment  of,  158. 
Relapsing  syphilis,  21. 
Renner,  366. 

Rcsorbin  blue  ointment,  185. 
Restlessness  in  hereditary  syphilis,  522. 
Retinitis.     See  Chorio-retinitis. 
Rheumatism,    differentiation    of,    from 
syphilis,  445. 
syphilitic,  445. 
Rhinitis,  atrophic,  366. 
Ribs,  hereditary  syphilis  of,  521. 

occurrence  of  syphilis  in,  425. 
Richards,  28,  367. 
RicoRD,  214,  265,  336. 
Ricord's  theory  of  syphiHs,  13. 
RiLLE,  24. 


Ringworm  differentiated  from  syphilis, 
300. 

ROCHION-DUVIGNEAUD,  388. 

Roentgen    rays    in    diagnosis    of    bone 
syphihs,  436. 

ROSCHER,   28,   199. 
ROSENBERGER,  23. 

Roseola  of  larynx,  453. 

of  mouth,  337. 

of  skin,  281. 

of  trachea,  460. 
ROSINSKI,  69. 
Routine  treatment  of  syphilis,  139,  151. 

hereditary,  540. 
Rotrx,  22,  31,  32. 
RUGGLES,  6. 
Rupia,  323. 

treatment  of,  324. 
Rupture  of  gumma  into  bronchus,  465. 

Saber  tibia,  531. 
Sachs,  27. 

.Saddle-backed  nose,  365. 
Sajodin,  199. 

Salicylate  of  mercury,  175. 
Salivary  glands,  syphilis  of,  492. 
Salivation,  following  cessation  of  mer- 
curial injections,  179. 
from  mercurial  injections,  181. 
iodic,  195. 
mercurial,  162. 

absent  in  infancy,  541. 
symptoms  of  mild,  162. 

severe,  163. 
treatment  of,  163. 
Saturated  solution  of  potassium  iodid, 

196. 
Savre,  27. 

Scab  of  syphilids,  274. 
Scabies,  differential  diagnosis  of,  ixom 

chancre,  245-246. 
Scale  of  syphilids,  274. 
Scalp,  acneiform  syphilid  of,  295. 
framboesia  of,  312. 

lesions  of,  in  hereditary  syphilis,  516. 
pustular  syphilid  of,  311. 
vegetating  syphilid  of,  311. 
Scapula,  occurrence  of  syphihs  in,  425. 


S68 


INDEX 


Scar  of  syphilids,  274. 
Scarlatina   differentiated  from  macular 
syphilid,  286. 

SCHADLE,  362. 
SCHAUDINN,  22,  28. 
SCHERBER,  31. 
SCHNABEL,  377. 
SCHNITEZELER,  458. 
SCHOLTZ,  28. 

Schuster,  i6i. 
Scleral  gumma,  422. 
Scleritis,  422. 
Sclerosis  of  heart,  485. 

of  liver,  470. 

of  lungs,  464. 

of  tongue,  356. 
Sclerotic   lesions,    mixed   treatment   of, 

148. 
Scott,  122. 
Seborrhea,  273. 
Second  attack  of  syphilis,  43. 
Secondary  and  tertiary  lesions,   differ- 
entiation between,  83. 
Secondary  incubation,  duration  of,  80. 
Secondary-  lesions,  14,  83. 

definition  of,  83. 

diagnosis  of,  120. 

duration  of,  87. 

early,  85. 

late,  cases  of,  88,  99. 

infectious,    effect    of    tobacco    on, 

95- 
infectiousness  of,  93. 
prevention  of,  94. 
regions  involved  by,  92. 
rare  occurrence  of,  87. 
relapses  of,  86. 
spirocheta  in,  28. 
treatment  of,  by  mercury,  147. 
Secondary  outbreak,  diagnosis  of,  120. 
Secondary  syphiHds.     See  Syphilids. 

differentiation  of,  from  tertiary,  275. 
Secondary  toxemia,  84. 

local  symptoms  of,  85. 
Secretions,  virulence  of,  53. 
Sensory  disturbances  in  spinal  syphilis, 

404. 
Seminal  vesicles,  syphilis  of,  502. 


Separation  of  nail,  syphiUtic,  310. 
Sepsis  in  hereditary  syphilis,  524. 
Sergent,  524. 
Serpiginous  ulcer,  319. 
Serum,  Wassermann,  34. 
Serum  diagnosis,  34. 
Serum  treatment,  34. 
Severity  of  tropica!  syphilis,  41. 
Sex,  effect  of.     See  Woman. 
Sexual   power  impaired  in  syphiKs   of 
nervous  system,  379. 

lost  in  spinal  syphilis,  403. 
Shape  of  spirocheta,  23. 
Siebert,  27. 
Siegel,  22. 
Silent  type  of  liver  syphilis,  476. 

of  pulmonary  syphilis,  467. 
SiMONELLi,  25. 

Sixth  cranial  nerve,  paralysis  of,  388. 
Skin,  syphilis  of.     See  Syphilid. 
Skull,  syphilis  of,  439. 

hereditary,  520. 
Sleeplessness  in  hereditary  syphilis,  522. 
Slow   and   progressive   development   of 

syphilids,  272. 
Smallpox   differentiated    from    sypliiHs, 

293- 
Smoker's  tongue,  352. 
Snuffles  in  hereditary  syphihs,  510. 

SOBERNHEIM,    23,    28,    269. 

Sodium  iodid,  199. 

Soft  chancre.     See  Chancroid. 

Soft  palate.     See  Velum. 

Soles,  syphilis  of.     See  Palms. 

Soluble     injections     of     mercurj'.     See 

Mercury,  Injections  of. 
South  Sea  Islanders,  immunity    of,    to 

syphilis,  41. 
Spastic  syphiHtic  paraplegia,  112. 
Specific  tonics  in  treatment  of  sypliihs, 

143- 
Sphenoidal  fissure,  nerve  symptoms  due 

to  lesions  of,  388. 
Spiess,  496. 
Spillmann,  94. 

Spinal  cord.     See  also  Spinal  Syphihs. 
gumma  of,  375. 
syphilis  of,  403. 


INDEX 


569 


Spinal  syphilis,  443. 

anesthesia  in,  404. 

ataxia  in,  405. 

ataxic  type  of,  407. 

bladder  paralyzed  in,  407. 

diagnosis  of,  409. 

hemiplegia  in,  404. 

numbness  in,  404. 

ocular  symptoms  of,  405. 

paralysis  in,  404. 

paresthesia  in,  404. 

sensory  disturbances  in,  404. 

trophic  disturbances  in,  405. 
Spinal  syphiUtic  meningitis,  406. 
Spirochela  huccalis,  27. 
Spirocheta  pallida,  23. 

cause  of  syphilis,  11. 

description  of,  23. 

diagnosis  of,  26. 

discovery  of,  22. 

disposition  of,  in  lesions,  51. 

distribution  of,  27. 

fate  of,  29. 

frequency  of,  27. 

in  blood,  28,  54. 

in  hereditary  syphilis,  29. 

in  lymph  nodes,  28. 

in  primary  lesion,  28. 

in  secondary  lesions,  28. 

in  tertiary  lesions,  29. 

method  of  increase  of,  47 

persistence  of,  37. 

phagocytosis  of,  30. 

stains  for,  24. 

vitaUty  of,  32. 
Spirocheta  refringens,  27. 
Spironema.     See  Spirocheta. 
Spleen,     enlarged,     in     early    syphilis, 
265. 
in  rachitis  later  than  in  hereditary 

syphihs,  528. 
with  liver  syphilis,  474. 

in  hereditary  syphihs,  522. 
Spontaneous  fracture    due    to    syphilis, 

433- 
Springtime  roseola   differentiated   from 

macular  syphilid,  286. 
Squamous  paronychia,  310. 


Squamous  syphilid,  296. 

diagnosis  of,  299. 

generalized,  296. 

guttate,  296. 

of  palms  and  soles,  303. 
diagnosis  of,  308. 

treatment  of,  309. 
Squint  due  to  paralysis  of  motor  oculi, 

387- 
Stahelin,  28. 
Staining  of  spirocheta,  24. 
Starch,  iodid  of,  199. 
Starr,  405. 

Statistics.     See  Statistics  xxvii. 
Sternum,  syphihs  of,  442. 

occurrence  of  syphilis  in,  425. 
Stigmata  of  hereditary  syphilis,  532. 
Stillbirths  in  hereditary  syphilis,  65. 
Stokes-Adams  syndrome,  486. 
Stomach,  syphilis  of,  493. 
Stricture  of  esophagus,  493. 

of  rectum,  495. 
Stridor  thymicus  in  hereditary  syphihs, 

527- 
Stomatitis,  differential  diagnosis  of,  343. 

mercurial,  162. 
Stranski,  385. 
Streptobacillus  of  Ducrey,  206. 

in  bubo,  215. 
Strontium  iodid,  199. 
Sturgis,  6g. 
Subcutaneous  gumma,  327. 

comphcations  of,  332. 

confluent,  331. 

differential  diagnosis  of,  332. 

discrete,  330. 

healing  of,  331. 

incision  of,  331. 

local  treatment  of,  335. 

pathology  of,  327. 

prognosis  of,  332. 

symptoms  of,  330. 

treatment  of,  335. 

ulcer  of,  331. 
Succus  altcrans  in  treatment  of  syphilis, 

144. 
Subcutaneous    injections    of    mercury. 
See  Mercury,  Injection  of. 


57° 


INDEX 


Subcutaneous  inoculation  vnth  syphiKs, 

32. 
Superior  maxilla,  occurrence  of  syphilis 

in,  425. 
Surgeon  General's  report  of  venereal  dis- 
ease in  army,  3. 
Surgical  treatment.    See  Operative  treat- 
ment. 
Susceptibility  to  syphilis,  39. 
Symptomatic  treatment  of  syphilis,  147. 

See  also  Treatment. 
Syphilid,  bullous,  292. 
circinate,  273. 

crusted.     See  Pustular  Syphihd. 
erosive.     See    Mucous  Papule, 
macular.     See  Macular  Syphilid, 
papular.     See  Papular  Syphilid, 
pustular.     See  Pustular  Syphilid, 
squamous.     See  Squamous  Syphilid, 
tubercular.     See  Tubercular  Syphilid, 
ulcerative.     See  Ulcerative  Syphilid, 
vesicular.     See  Vesicular  Sypliilid. 
Syphilids,  cHnical  characteristics  of,  271. 
color  of,  273. 
crust  of,  274. 
differentiation  between  secondary  and 

tertiary,  275. 
form  of,  273. 
hereditary,  512.     See  also  Hereditary 

Syphihds. 
inflammation  absent  from,  272. 
itching  absent  from,  272. 
of  face,  312. 
of  mucous  membranes.     See  Mucous 

Membranes. 
of  palms.     See  Palms, 
of  scalp,  311. 
of  soles.     See  Palms, 
painless,  272. 

pathological  characteristics  of,  278. 
polycycHc,  273. 
polymorphism  of,  272. 
rounded  form  of,  273. 
scab  of,  274. 
scale  of,  274. 
scar  of,  274. 
secondary,  280. 
secondary,  characteristics  of,  275. 


Syphihds,  secondary,  treatment  of,  277. 
slow  and  progressive  development  of, 

272. 
tertiary,  313. 

characteristics  of,  275. 
treatment  of,  277. 
ulceration  of,  274. 
SyphiKs,  acquired,  13. 
in  infancy,  74. 
albuminuria  in,  497, 
alopecia  of,  265. 
amyloid  disease  in,  270. 
and  alcohol,  19,  103,  129. 
and  appendicitis,  494. 
and  arteriosclerosis,  106. 
and  atrophic  rliinitis,  366. 
and  cHmate,  127. 
and  debihty,  128. 
and  environments,  127. 
and  epilepsy,  106. 
and  glycosuria,  106. 
and  life  insurance,  133. 
and  marriage,  4,  61. 

moral  aspects  of,  64. 
and  maternity,  65. 
and  neurasthenia,  106. 
and  non-union  in  fracture,  433. 

and  paresis,  108. 

and  spontaneous  fracture,  433. 

and  tabes,  108. 

and  tuberculosis,  19. 
hereditary,  524,  538. 

and  trauma,  38,  128. 

and  yaws,  39. 

differential  diagnosis  of,  122. 

hinaria,  76. 

blood  changes  in  early,  254. 

cases  of.     See  Cases  Cited  xxv. 

causes  of  death  in,  136. 

cervical  nodes  in,  263. 

chronic  toxemia  of,  266. 

clinical  diagnosis  of,  117. 

clinical  types  of,  18. 

congenital.     See  Hereditary  Syphilis. 

course  of,  18,  78. 

danger  of,  in  marriage,  62. 

debility  from,  259. 

definition  of,  11. 


INDEX 


571 


Syphilis,  delayed  hereditan',  17,  528. 
diagnosis  of,  113.     See  also  Diagno- 
sis. 
at  different  periods  of  disease,  121. 
by  atrophy  of  tongue  papillae,  119. 
by  biopsy,  116. 
by  effect  of  treatment,  119. 
by  history,  117. 
by  inoculation,  116. 
by  Justus  test,  116. 
by  scars,  118. 
by  serum,  34. 
by  spirocheta,  115. 
by  Wassermann  serum,  34. 
clinical,  117. 

differential,  121.     See   also   Differ- 
ential Diagnosis, 
pathological,  115,  328. 
duration  of,  132. 

infectiousness  of,  61. 
hereditary,  16. 
etiology  of,  22. 
expectation  of  life  in,  136. 
experimental,  30. 
fetal,  17,  506. 
fe\er  of  early,  257. 

of  late^  268. 
Finger's  theory  of,  ^6. 
general  characteristics  of,  11. 
headache  of  early,  264. 
hereditary,   75.     See  also  Hereditary 
Syphihs. 
cases  of.    See  Cases  Cited  xxv. 
history  of,  12. 
hygiene  of,  140. 
immunity  to,  41. 
impi-ovement  in  treatment  of,  42. 
in  monkeys,  31. 
in  relation  to  public  health,  i. 
in  Orient,  severity  of,  41. 
in  tropics,  severity  of,  41. 
in  woman.     Sec  Woman, 
incidence  of,  2.     See  also  Statistics, 
age  of,  58. 
late  lesions  of,  104. 
secondary  symptoms  of,  83. 
tertiary  symptoms  of,  96. 
infantile.     See  Hereditary  SyphiUs. 


Syphilis,  infectiousness  of.     See  Infec- 
tiousness, 
inheritance  of,  65. 
insontium,  57. 
interaction    of,    with    other    diseases 

and  diatheses,  12. 
jaundice  of.     See  Jaundice. 
Justus's  test  for,  116. 
Lang's  theory  of,  36. 
lesions    of.     See    Syphihs,  Pathology 

of. 
loss  of  weight  from,  259. 
malignant  early,  19. 
malignant  late,  21. 
means  of  diagnosis  of,  115. 
mediate  infection  with,  32. 
mild  but  persistent,  20. 
mild  early,  18. 
mild  late,  21. 

modes  of  transmission  of,  13. 
mortality  of,  135. 
nature  of,  35. 

neonatorum.     See  Hereditary  Syphi- 
hs. 
nephritis  in,  497. 
nervous  symptoms  of  early,  260. 
Neumann's  theory  of,  36. 
nocturnal  pains  of,  263. 
occult,  in  woman,  16,  45. 
of    various    regions    or    tissues.     See 

regions  or  tissues  involved, 
onset  of,  in  man,  78. 

in  woman,  79. 
oriental,  severity  of,  41. 
osteocopic  pains  of,  263. 
pathology  of,  46,  327. 
periods  of,  15. 
pigmentation  from,  275. 
prevalence  of,  2. 
prevention  of,  138. 
principles  of  prophylaxis  of,  8. 

of  treatment  of,  139. 
probabiUty   and   possibility   of  infec- 
tion with,  59. 
prognosis  of,  124. 
effect  of  age  on,  128, 
of  alcoholism  on,  129. 
of  cUmate  on,  127. 


572 


INDEX 


S}'philis,  prognosis  of,  effect  of  debility 
on,  128. 
of  environment  on,  127. 
of  patient's  constitution  on,  125. 
of  patient's  habits  on,  129. 
of  time  on,  131. 
of  tobacco  on,  130. 
of  trauma  on,  128. 
of  treatment  on,  131. 
prophylaxis  of,  6,  32. 
by  cauterization,  138. 
by  excision  of  chancre,  138. 
by  mercurial  inunction,  33. 
reinoculation  with,  32. 
relapses    of.     See    Relapse,    Tertiary 
Relapse, 
not  prevented  by  iodid,  145. 
prevented  by  mercury,  145. 
relapsing,  21. 
routine  treatment  of,  139. 

of,  by  injections,  179. 
second  attack  of,  42. 
secondary  fever  of,  257. 
secondary  incubation  of,  80. 
secondary  lesions  of,      14,     83,     261. 
Classified    also    under    lesions 
themselves. 
at  onset,  86. 
diagnosis  of,  83. 
duration  of,  87,  91,  92. 
late,  92. 

infectiousness  of,  93. 
rarer,  87. 
relapse  of,  87. 
spirochetae  in,  28. 
treatment  of,  94,  147. 
outlook  of,  86. 
diagnosis  of,  120. 
secondary  period  of,  15. 
secondary  toxemia  of,  84,  253. 
splenomegaly  in  early,  265. 
susceptibility  to,  39. 

tables  of.     See  Statistics  xxvii. 
tertiary  lesions  of,  14,  95.     Classified 
also  with  the  various  lesions, 
diagnosis  of,  83. 
distribution  of,  103. 
effect  of  alcohol  on,  103,  129. 


Syphilis,  tertiary  lesions  of,  incidence  of, 
96. 

prevention  of,  loi. 

prognosis  of,  97,  131. 

relapse  of.     See  Tertiary  Relapse. 

spirochetae  in,  29. 

treatment  of,  loi,  147. 
tertiary  period  of,  15. 
tertiary  relapses  of,  97. 
theories  of,  36. 

hereditary,  69. 
thrombosis  in,  50. 
tonics  in,  143. 
toxemia  of,  19,  253. 

hematology  of,  254. 
transmission  of,  53. 
treatment  of.     See  also  Treatment. 

abortive,  138. 

at  Aachen,  141. 

at  Hot  Springs  of  Arkansas,  141. 

by  atoxyl,  145. 

by  fumigation,  188. 

by  hygiene,  140. 

by  injections,  175. 

by  inunctions,  185. 

by  iodid,  195. 

by   mercury   in   tonic    doses,    145. 
See  also  Mercury. 

by  specific  tonics,  143. 

by  succus  alterans,  144. 

by  tonics,  143. 

by  Zittmann's  decoction,  143. 

choice  of,  146,  151. 

continuous  tonic,  154. 

duration  of,  149. 

in  America,  154. 

in  England,  154. 

in  France,  153. 

in  Germany,  153. 

in  Italy,  153. 

instructions  to  patient  in,  155. 

interrupted,  152. 

lesions     of,     147,     159.     See     also 
Treatment. 

local,  150.     See  also  Local  Treat- 
ment. 

modern  interrupted  method  of,  153, 

principles  of,  138. 


INDEX 


573 


Syphilis,    treatment    of,    routine,     130, 

151- 
symptomatic,  147,  159. 

by  mercurial  injections,  179. 
tonic,  145,  155- 

after  late  relapses,  158. 
duration  of,  157. 
interruptions  in,  157. 
two  objects  of,  138. 
vigorous  interrupted,  152. 
when  to  begin  routine,  158. 
uncertain  propriety  of  treating,  159. 
Unna  theory  of,  36. 
Virchow's  theory  of,  36. 
virus  of,  vitality  of,  32. 
Syphilitic.     See  Syphilis.     See  also  the 

various  lesions. 
Sypliilitic  dystrophies.     See  Parasyphi- 
Hds. 
hereditary,  525. 
Syphilization,  13. 
Syphiloma.     See  also  Gumma, 
ano-rectal,  494. 
of  larynx,  455. 
of  nose,  366. 
Syphilophobia,  114,  260. 
Syrup  of  hydriodic  acid,  199. 

Tabes,  age  at  onset  of,  108. 
and  syphilis,  108. 
date  di  onset  of,  372. 
diagnosis  of,  no. 

by  lymphocytosis  of  cerebro-spinal 
fluid,  376. 
etiology  of,  107. 
frec[ucncy  of,  in  syphilitics,  108. 

in  women,  108. 
pathology  of,  109. 
prognosis  of,  in. 
treatment  of,  in. 
Tables    of    differential    diagnosis.     See 
Differential  Diagnosis, 
of  statistics.     See  Statistics  xxvii. 
Tachycardia,  functional,  4S5. 
Tannate  of  mercury,  171. 
Tar   ointment   for   squamous   syphilid, 

309- 
Tarn'ier,  509. 


Taejstowski,  75,  91. 

Tarsitis,  423. 

Tarsus,  occurrence  of  syphilis  in,  425. 

Taylor,  75,  441,  517. 

Tear  duct,  syphilis  of,  423. 

Technic  of  mercurial  injections,  177. 

Teeth,  care  of,  163. 

deformities  of,  in  hereditary  syphilis, 

534- 
Tegumentary  chancre,  238. 
Temporal  bone,  occurrence  of  syphilis 

in,  425. 
Tendon  sheaths,  syphilis  of,  451. 
Tendons,  syphilis  of,  449. 
Terrien,  411,  419. 
Tertiarism.     See  Tertiary  Lesions. 
Tertiarisme  d'emblee,  96. 
Tertiary  and  secondary  lesions,  differen- 
tiation between,  83. 
Tertiary  ecthyma,  323. 
Tertiary  lesions,  14,  95. 
definition  of,  95. 
early,  19,  96. 
occurrence  of,  96. 

of  various  regions.     See  various  tis- 
sues involved, 
relapses  of,  97. 

effect  of  alcohol  on,  103. 

of  treatment  on,  loi. 
intervals  between,  98. 
regions  involved  by,  103. 
spirocheta  in,  29. 
Tertiary  syphilids.     Sec  Syphilids. 
Tertiary  ulcer,  324. 
Test  of  treatment,  205. 

in  syphilis  ?)f  nervous  system,  410. 
Testicle,  atrophy  of,  in  hereditary  syph- 
ilis, 521. 
in   hereditary  sypMlis,  521. 
syphilis  of,  478. 
bilateral,  478. 
diagnosis  of,  481. 
occurrence  of,  478. 
pathology  of,  479. 
prognosis  of,  480. 
symptoms  of,  480, 
treatment  of,  481. 

TiTALMANN,  35. 


574 


INDEX 


Theories  of  syphilis,  36. 
Theory  of  minimum  dose,  173. 

of  syphilitic  heredity,  69. 
Third  cranial  nerve,  paralysis  of,  387. 
Third  generation,  hereditar}'  s>^hihs  of, 

75- 
Thrombosis  due  to  s\T)hilis,  50. 
Tibia,  occurrence  of  s}'pluHs  in,  425. 
Time  the  cure  of  syphihs,  131. 
Tincture  of  iodin,  199. 
TiSELius,  134. 

Tobacco  and  the  prognosis  of  sj'phiHs, 
130. 
a  cause  of  leukoplakia,  353.  • 
a  cause  of  relapse,  39. 
influence  of,  on  late  infectious  secon- 
darj'  lesions,  95. 
on  s}'philis  of  mouth,  350.- 

TOEPEL,   28. 

TOSL\SCZEWSKI,   28,   29,   207,   215. 

Tongue,  atrophy  of  large  papillae  of,  119. 

chancre  of,  237. 
diagnosis  of,  251. 

erosions  of,  337. 

gumma  of,  356. 
diagnosis  of,  357. 

interstitial  inflammation  of,  356. 

leukoplakia  of.     See  Leukoplakia. 

mucous  papules  of,  338. 

sclerosis  of,  statistics  of,  350. 

secondar}'  lesions  of,  337. 

squamous  sj'philids  of.     See  Leuko- 
plakia. 

tertiary  lesions  of,  352. 
Tongue  ulcer,  statistics  of,  350. 
Tonic  effect  of  mercur)',  145. 
Tonic  treatment,  155. 

after  late  relapses,  158. 

of  hereditar}'  s}'philis,  538. 
Tonics  in  treatment  of  sj-philis,  143. 
Tonsil,  chancre  of,  237. 

gumma  of,  358. 

inJiltration  of,  358. 

secondary  lesions  of,  337. 

tertiary'  lesions  of,  358. 
statistics  of,  350. 
Torticollis,  447. 
Total  incubation,  duration  of,  80. 


Toxemia,  iodic,  194. 
secondar}',  19,  84,  253. 

marked  in  women,  46,  85,  254. 
tertiar}',  267. 
Toxicology  of  iodids,  192. 

of  mercury,  162. 
Trachea,  eroded  papules  of,  460. 
gum.ma  of,  461. 
roseola  of,  460. 
syphihs  of,  460. 
diagnosis  of,  468. 
pathology  of,  460. 
statistics  of,  460. 
symptoms  of,  466. 
treatment  of,  46S. 
Tracheal   type   of   puhnonary   syphilis, 

467. 
Tracheotomy  for  S}'phiKs  of  larynx,  460. 

for  sypliihs  of  trachea,  461. 
Transmission  of  syphilis,  13,  53. 
from  child  to  parent,  16,  70. 
from  parent  to  child,  16,  65. 
in  matrimony,  61. 
Transverse  myeHtis,  syphihtic,  406. 
Trauma  and  syphihs,  38,  128. 

of  bone,  426. 
Treatment,  antis}'pliihtic,  138. 
by  iodid.     See  lodid. 
by  mercur}'.     See  ]SIercury. 
by  serum,  34. 

effect  of  early,  on  s}'phihs  of  ner- 
vous system,  369. 
in  diagnosis  of  S3'philis,  119. 
on  prognosis  of  syphihs,  131. 
local.     See  Local  Treatment, 
improvement  in,  42. 
mixed,  202. 

of  aortic  aneurism,  488. 
of  arthritis,  447. 
of  bone  syphihs,  437. 
of  bronchial  syplrilis,  46S. 
of  cerebral  s}'phihs,  383. 
neglected,  385. 
operative,  385. 
of  chancre,  233. 
of  chancre  redux,  483. 
of  condyloma,  346. 

in  hereditary  syphihs,  541. 


INDEX 


575 


Treatment,    antisyphilitic,   of   deafness, 

396- 
of  erosive  syphilid,  346. 
of  erosions  in  hereditary  syphilis, 

541. 

of  father,  effect  of,  on  child,  71. 

of  gumma,  147. 

of  gumma  of  palate,  363. 

subcutaneous,  335. 

of  hereditar}'  syphihs,  539. 

of  iritis,  415. 

of  keratitis,  532. 

of  kidney  syphilis,  498. 

of  lar}'ngeal  syphilis,  459. 

of  larj'ngitis,  secondar}',  454. 

of  lesions  of  syphilis,  147,  159. 

of  leukoplakia,  355. 

of  liver  syphilis,  477. 

of  mother  to  prevent  sj'philis  of 
fetus,  439. 

of  mouth  lesions,  secondar)'-,  347. 

of  nasal  gumma,  366. 

of  onychia,  311. 

of  optic  neuritis,  421. 

of  orcliitis,  481. 

of  pains  of  early  syphilis,  147. 

of  palate  gumma,  363. 

of  parasyphiUds,  in. 

of  parenchymatous  keratitis  in  he- 
reditary syphihs,  532. 

of  paresis,  in. 

of  paronychia,  311. 

of  pulmonary  syphilis,  46S. 

of  rupia,  324. 

of  sclerotic  lesions,  148. 

of  secondary  lesions,  147. 

of  secondary  meningitis,  378. 

of  secondary  syphiHds,  277. 

of    snuffles    in   hereditary    syphilis, 

541- 
of  squamous  syphihd  of  palms,  309. 
of  syphihs  of  nervous  system,  148, 

'383- 
of  tabes,  in. 
of  tertiary  lesions,  147. 
of  tertiary  syphilids,  277. 
of  toxemia,  147, '257. 
of  tracheal  syphilis,  461,  468. 


Treatment,  antis}'phihtic,  of  ulcerative 
syphilid,  327. 
of  uninfected  children  in  a  sj'phi- 

litic  family,  540. 
of  velum  gumma,  362. 
principles  of,  138. 
routine,  139,  151. 
sjTnptomatic,  147,  159. 
test,  course  of,  205. 
tonic,  145,  155. 
of  adenitis  of  chancroid,  221. 
of  chancroid,  217. 
Treponema  pallida.     See  Spirocheta  pal- 
lida. 
Tripier,  462. 

Tropical  s}'philis,  severity  of,  41. 
Trophic  disturbances  in  spinal  syphihs, 

405- 
Tubercle,  314. 

pathology  of,  279. 
Tubercular  syphihd,  314- 

confluent,  314. 

crusted,  322. 

diagnosis  of,  317. 

disseminated,  314. 

grouped,  314. 

hereditar\',  517. 

massed,  314. 

of  glans  penis,  481  = 

phagedenic,  320. 

serpiginous,  319. 

treatment  of,  317. 

ulcerative,  318. 

type  of  pulmonary  syphilis,  467. 
Tuberculosis,    comphcating   syphihs   of 
lung,  465. 

differentiated  from  syphilis  of  testicle, 
481. 

of  bone  differentiated  from  syphilis, 

436- 
of  kidney,  syphihs  mistaken  for,  500. 
of  knee,  simulated  by  acquired  sj'phi- 

hs,  447. 
hereditar}'  s}TDhilis,  529. 
of  larynx  differentiated  from  syphilis, 

458- 
of  lung  differentiated  from  syphilis, 

468. 


576 


INDEX 


Tuberculosis  of  spine  differentiated  from 
syphilis,  443. 
of  testicle  differentiated  from  acquired 
syphilis,  480. 
from  hereditar}'  syphiHs,  521. 
relation  of,  to  syphilis,  19. 

hereditarv',  524,  53S. 
use  of  merciu^'  in,  167. 
Tumor.     See  Neoplasm. 
Tunica  vaginalis,  syphilis  of,  480. 
Turbinate  bones,    fibroid   degeneration 
of,  366. 
syphiHs  of,  364. 
Tylosis.     See  Leukoplakia. 
Types  of  s}'philis,  clinical,  18. 
of  chancre,  225. 

Ulcer,  gummatous,  331. 

of  bladder,  501. 

of  bronchi,  461. 

of  glans  penis,  481. 

of  larynx,  tertiars',  454. 

of  nose,  364. 

of  palate,  363. 

of  pharynx,  359. 

of  stomach,  and  s^'philis,  493. 

of  trachea,  461. 

of  velum,  360. 

S)^hilitic,  274. 
secondary,  342. 
tertiary,  324. 
Ulcerated  chancre,  226. 
Ulcerated  condyloma,  342. 
Ulcerated  gums,  treatment  of,  164. 
Ulcerated  onychia,  310. 
Ulcerated  paronychia,  311. 
Ulcerated  syphilids,  318. 

diagnosis  of,  326. 

differential  diagnosis  of,  327. 

of  mucous  membrane,  342. 

phagedenic,  320. 

prognosis  of,  325. 

serpiginous,  319. 

treatment  of,  327. 

tubercular,  318. 
Ulna,  occurrence  of  syphilis  in,  425. 
Unalist's  theory  of  s\'philis,  13. 
Unna,  207. 


Unna's  theorj'  of  sj'phiHs,  36. 
Urethral  chancre,  235. 

frequency  of,  82. 
Urethritis,  iodic,  195. 
Urinar}'^  organs,  syphihs  of,  495. 
Urticaria    differentiated    from    macular 

sj'phihd,  286. 
Uterus,  s}'philis  of,  503. 
Uveal  tract,  gumma  of,  421. 

Vaccinal  chancre,  238. 
Van  Walsen,  55. 
Vaqtjez,  489. 

Varicella,  differentiation  of,  from  syph- 
ilis, 293. 
A'aricelloid  sj'philid,  293. 
Varicose  ulcer  distinguished  from  sub- 
cutaneous gumma,  334. 
Varieties  of  papular  sj'phihd,  290. 

of  parasyphiUds,  105. 
Variola,  diagnosis  of,  from  s}'phiHs,  293. 
Varioloid  syphilid,  293. 
Vas  deferens,  syphiHs  of,  480. 
Vasogen  blue  ointment,  185. 
Vegetating  papule.     See  Condyloma. 
Vegetating  syphiHd  of    scalp,  311. 
Vegetations  of  face,  312. 
Veins,  syphiHs  of,  489. 
Velum,  erythema  of,  337. 

gumma  of,  360. 

interstitial  inflammation  of,  359. 

perforation  of,  360. 

tertiar}'  sj-phiHs  of,  statistics  of,  350. 

treatment  of  lesions  of,  362. 

ulcer  of,  360. 
Vertebral  column,  s3T3hilis  of,  443. 
Vertigo,  date  of  onset  of,  372. 

prodrome  of  s}'phiHs  of  nervous  sys- 
tem, 380. 
Vesicle,  patholog}'  of  syphilitic,  279. 
Vesicular  sj'phiHd,  292. 
Vessels,  lesions  of  larger,  51. 
of  smaller,  49. 

VOCKERODT,   24. 
VOLPINO,   22. 

Von  Duhring,  488. 

Voss,  438. 

Vox  ratica,  457,  519. 


INDEX 


577 


Vitality  of  spirocheta,  32. 

of  syphilitic  virus,  32. 
Vitiligo,  differentiation  of,  from  syphilid, 

201. 
Vigorous  interrupted  method  of  treating 

syphilis,  152. 
Vincent's  angina,  249. 
ViRCHOW,  462. 

Virchow's  theory  of  syphilis,  36. 
Virulence  of  secretions,  53. 
Virulent  bubo,  215. 
treatment  of,  221. 
Viscera,  inflammation  of,  in  hereditary 

syphilis,  521. 
Vision  dim  in  chorio-retinitis,  417. 

Wassermann  serum,  34. 

Wellman,  122. 

Wesenberg,  199. 

When  to  begin  routine  treatment,  158. 

Whistler,  456. 

White  blood  cells  in  early  syphihs,  255. 

WiELANDER,   l6l,   19O. 

Williams,  35. 
woelfert,  265. 


Woman,  lesions  at  secondary  outbreak 
of  syphilis  in,  86. 
not  liable  to  parasyphilids,  45. 
occult  syphilis  in,  16,  45,  79. 
onset  of  syphilis  in,  79. 
primary  lesion  absent  in,  45. 
rarer  secondary  lesions  in,  87. 
rarity  of  tabes  in,  45,  108. 
secondary  lesions  absent  in,  83. 
syphihs  in,  45. 
syphilitic  toxemia  severe  in,  46,  85, 

254- 
Wracek,  55. 

X-ray  in  diagnosis  of  bone  syphilis,  436. 

Yaws  and  syphilis,  differential  diagnosis 

of,  122. 
Yellow  iodid  of  mercury,  170. 

Zabriskie,  E.  G.,  368,  386,  405. 

Zinc  oxid  ointment  for  squamous  s)^h- 

ilid,  309. 
Zittmann's  decoction,  143. 


(1) 


THE    END 


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